| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,648 |
1,638 |
$70K |
| D1206 |
Topical application of fluoride varnish |
1,912 |
1,902 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
316 |
119 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,452 |
1,446 |
$37K |
| D1351 |
Sealant - per tooth |
1,065 |
266 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
472 |
465 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
278 |
144 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
186 |
$19K |
| D0272 |
Bitewings - two radiographic images |
972 |
966 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
238 |
102 |
$16K |
| D1110 |
Prophylaxis - adult |
332 |
332 |
$15K |
| D9248 |
|
54 |
54 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
132 |
$11K |
| D0603 |
|
1,179 |
1,177 |
$10K |
| D0240 |
|
465 |
389 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
294 |
294 |
$8K |
| D0274 |
Bitewings - four radiographic images |
178 |
178 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
30 |
$5K |
| D1330 |
|
950 |
946 |
$4K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
224 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
20 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
89 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$289.80 |
| D0602 |
|
27 |
27 |
$270.00 |
| D9995 |
|
16 |
16 |
$80.00 |