| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,198 |
2,150 |
$100K |
| D1206 |
Topical application of fluoride varnish |
1,962 |
1,915 |
$79K |
| D1351 |
Sealant - per tooth |
2,541 |
568 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
452 |
219 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
973 |
944 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
493 |
311 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,156 |
1,133 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,194 |
1,163 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
647 |
318 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,928 |
1,877 |
$18K |
| D0274 |
Bitewings - four radiographic images |
738 |
722 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,555 |
2,090 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
803 |
691 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
356 |
335 |
$11K |
| D9310 |
|
210 |
207 |
$8K |
| D0330 |
Panoramic radiographic image |
185 |
176 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
95 |
58 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
68 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
235 |
231 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
24 |
$2K |
| D9248 |
|
29 |
12 |
$546.00 |
| D3120 |
|
39 |
24 |
$36.00 |