| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,145 |
1,130 |
$23K |
| D1120 |
Prophylaxis - child |
1,865 |
980 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
173 |
29 |
$22K |
| D1206 |
Topical application of fluoride varnish |
2,478 |
1,285 |
$16K |
| D1110 |
Prophylaxis - adult |
753 |
393 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
383 |
187 |
$8K |
| D0272 |
Bitewings - two radiographic images |
803 |
409 |
$6K |
| D1351 |
Sealant - per tooth |
462 |
56 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
226 |
105 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
113 |
$2K |
| D0274 |
Bitewings - four radiographic images |
185 |
90 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
212 |
64 |
$1K |
| D9420 |
|
17 |
13 |
$1K |
| D9215 |
|
174 |
115 |
$0.00 |