| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,851 |
1,819 |
$61K |
| D1206 |
Topical application of fluoride varnish |
2,310 |
2,272 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,772 |
1,753 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
305 |
297 |
$15K |
| D1110 |
Prophylaxis - adult |
310 |
307 |
$12K |
| D0272 |
Bitewings - two radiographic images |
654 |
647 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
92 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
87 |
27 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
101 |
38 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
214 |
$5K |
| D1354 |
|
388 |
151 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
493 |
483 |
$4K |
| D1351 |
Sealant - per tooth |
149 |
30 |
$4K |
| D0603 |
|
203 |
196 |
$2K |
| D2140 |
|
32 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
156 |
146 |
$1K |
| D9110 |
|
41 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D1330 |
|
254 |
243 |
$1K |
| D1310 |
|
101 |
90 |
$430.00 |