| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,602 |
3,602 |
$148K |
| D1206 |
Topical application of fluoride varnish |
3,621 |
3,621 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
831 |
513 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,979 |
2,979 |
$97K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
400 |
223 |
$74K |
| D0140 |
Limited oral evaluation - problem focused |
689 |
681 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,543 |
1,066 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,299 |
1,299 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,598 |
1,583 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
176 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
381 |
$22K |
| D9248 |
|
144 |
144 |
$9K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
26 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$3K |
| D1351 |
Sealant - per tooth |
88 |
39 |
$3K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,225 |
1,210 |
$0.00 |