| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,063 |
7,039 |
$227K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,796 |
3,785 |
$134K |
| D1206 |
Topical application of fluoride varnish |
6,205 |
6,181 |
$115K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
734 |
205 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,078 |
3,065 |
$70K |
| D7962 |
|
497 |
493 |
$70K |
| D7140 |
Extraction, erupted tooth or exposed root |
963 |
530 |
$65K |
| D0272 |
Bitewings - two radiographic images |
2,530 |
2,521 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
687 |
470 |
$51K |
| D7961 |
|
359 |
356 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,777 |
1,680 |
$49K |
| D1351 |
Sealant - per tooth |
1,938 |
675 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
1,079 |
1,072 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,544 |
1,080 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,614 |
1,597 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
228 |
$17K |
| D0274 |
Bitewings - four radiographic images |
372 |
369 |
$11K |
| D9420 |
|
133 |
133 |
$10K |
| D0330 |
Panoramic radiographic image |
164 |
164 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
447 |
447 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
36 |
$4K |
| D0240 |
|
73 |
58 |
$1K |