| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,402 |
3,255 |
$175K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,335 |
554 |
$144K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,316 |
693 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,135 |
467 |
$61K |
| D1206 |
Topical application of fluoride varnish |
3,464 |
3,314 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,849 |
1,731 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,245 |
1,244 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
922 |
848 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,792 |
1,709 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,678 |
1,252 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
526 |
354 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,083 |
1,991 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
613 |
573 |
$20K |
| D0330 |
Panoramic radiographic image |
492 |
458 |
$19K |
| D1351 |
Sealant - per tooth |
746 |
239 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
327 |
310 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
87 |
55 |
$6K |
| D9420 |
|
73 |
71 |
$3K |
| D2330 |
|
21 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
28 |
$403.50 |