| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,994 |
1,912 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
422 |
164 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,971 |
1,888 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,320 |
1,306 |
$37K |
| D9310 |
|
1,477 |
1,450 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
901 |
800 |
$19K |
| D1351 |
Sealant - per tooth |
153 |
106 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
744 |
701 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
125 |
52 |
$10K |
| D0272 |
Bitewings - two radiographic images |
675 |
640 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
54 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
203 |
174 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
385 |
345 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
176 |
$2K |
| D1354 |
|
67 |
45 |
$2K |
| D0330 |
Panoramic radiographic image |
54 |
46 |
$1K |
| D1999 |
|
68 |
53 |
$0.00 |