| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,155 |
4,108 |
$238K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
706 |
284 |
$82K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,236 |
4,180 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,671 |
2,621 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,571 |
1,562 |
$48K |
| D0330 |
Panoramic radiographic image |
740 |
734 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,621 |
1,603 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
688 |
592 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
169 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
231 |
119 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
97 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
783 |
765 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
102 |
58 |
$7K |
| D1351 |
Sealant - per tooth |
160 |
53 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
126 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$429.00 |
| D1354 |
|
88 |
12 |
$372.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$335.10 |
| D1330 |
|
117 |
114 |
$321.86 |
| D1999 |
|
86 |
83 |
$0.00 |