| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,173 |
2,162 |
$129K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
925 |
377 |
$110K |
| D7140 |
Extraction, erupted tooth or exposed root |
786 |
377 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,683 |
1,673 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
750 |
410 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,268 |
2,258 |
$41K |
| D0330 |
Panoramic radiographic image |
562 |
552 |
$39K |
| D1351 |
Sealant - per tooth |
1,807 |
626 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
443 |
249 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
798 |
768 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
430 |
224 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,119 |
1,108 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
821 |
812 |
$22K |
| D1354 |
|
1,016 |
378 |
$12K |
| D1353 |
|
723 |
324 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
780 |
760 |
$10K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$8K |
| D7111 |
|
94 |
53 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
527 |
286 |
$5K |
| D9248 |
|
44 |
41 |
$4K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$4K |
| D2330 |
|
69 |
46 |
$4K |
| D2332 |
|
28 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$525.00 |
| D0603 |
|
233 |
229 |
$0.00 |