| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,565 |
6,512 |
$310K |
| D0120 |
Periodic oral evaluation - established patient |
3,153 |
3,131 |
$230K |
| D1310 |
|
3,608 |
3,580 |
$165K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,330 |
369 |
$156K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
153 |
149 |
$140K |
| D1206 |
Topical application of fluoride varnish |
6,080 |
6,032 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,652 |
1,644 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,668 |
813 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,224 |
5,023 |
$85K |
| D1351 |
Sealant - per tooth |
1,776 |
660 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,037 |
399 |
$58K |
| D0603 |
|
2,761 |
2,741 |
$41K |
| D9993 |
|
623 |
618 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,878 |
2,853 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
604 |
562 |
$24K |
| D0340 |
|
442 |
442 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
403 |
250 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
193 |
66 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,608 |
1,584 |
$19K |
| D9222 |
|
149 |
149 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
448 |
448 |
$15K |
| D0330 |
Panoramic radiographic image |
443 |
443 |
$13K |
| D9610 |
|
148 |
148 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
92 |
92 |
$6K |
| D2330 |
|
82 |
39 |
$6K |
| D9430 |
|
153 |
150 |
$5K |
| D0274 |
Bitewings - four radiographic images |
122 |
119 |
$3K |
| D0601 |
|
147 |
147 |
$2K |
| D0350 |
|
106 |
105 |
$710.40 |