| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,179 |
1,077 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,160 |
1,060 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
660 |
67 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
787 |
703 |
$22K |
| D0272 |
Bitewings - two radiographic images |
967 |
860 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
417 |
383 |
$8K |
| D1351 |
Sealant - per tooth |
414 |
89 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
248 |
78 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
131 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
248 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
53 |
$2K |
| D1354 |
|
249 |
38 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
220 |
160 |
$2K |
| D9248 |
|
65 |
37 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
160 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$602.70 |
| D9420 |
|
26 |
12 |
$450.89 |
| D0601 |
|
13 |
12 |
$60.00 |