| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,323 |
1,312 |
$75K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
663 |
187 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,309 |
1,301 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
414 |
195 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,366 |
1,357 |
$25K |
| D0330 |
Panoramic radiographic image |
351 |
349 |
$24K |
| D1351 |
Sealant - per tooth |
720 |
213 |
$16K |
| D0272 |
Bitewings - two radiographic images |
682 |
676 |
$14K |
| D1110 |
Prophylaxis - adult |
232 |
230 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
116 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
85 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
302 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
540 |
530 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
168 |
164 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
117 |
$5K |
| D0274 |
Bitewings - four radiographic images |
138 |
138 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
80 |
33 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
416 |
356 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
150 |
$2K |
| D2330 |
|
22 |
14 |
$1K |