| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,198 |
6,090 |
$162K |
| D1206 |
Topical application of fluoride varnish |
5,249 |
5,185 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,265 |
2,229 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,470 |
649 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
532 |
148 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
3,777 |
3,714 |
$48K |
| D1351 |
Sealant - per tooth |
2,737 |
815 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,074 |
651 |
$45K |
| D0330 |
Panoramic radiographic image |
829 |
815 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,511 |
1,416 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
701 |
432 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,107 |
2,070 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
1,221 |
1,157 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,703 |
1,647 |
$24K |
| D1110 |
Prophylaxis - adult |
828 |
818 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
832 |
820 |
$15K |
| D9994 |
|
4,823 |
4,743 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
925 |
911 |
$13K |
| D9420 |
|
107 |
105 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
862 |
265 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
706 |
678 |
$4K |
| D9310 |
|
32 |
32 |
$3K |
| D0274 |
Bitewings - four radiographic images |
219 |
213 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
14 |
$2K |
| D9248 |
|
14 |
12 |
$1K |
| D3110 |
|
51 |
24 |
$867.00 |
| D3120 |
|
21 |
20 |
$0.00 |
| D0170 |
|
13 |
13 |
$0.00 |