| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,740 |
3,728 |
$121K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
642 |
185 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,115 |
2,110 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,662 |
2,652 |
$51K |
| D7962 |
|
285 |
285 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
499 |
337 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,596 |
1,592 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
548 |
304 |
$37K |
| D7961 |
|
242 |
242 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,203 |
1,132 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,326 |
1,318 |
$27K |
| D1351 |
Sealant - per tooth |
878 |
317 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
559 |
557 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
876 |
873 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
917 |
568 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
151 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
875 |
867 |
$10K |
| D9420 |
|
131 |
131 |
$10K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$8K |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
14 |
$2K |