| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,329 |
1,845 |
$72K |
| D1206 |
Topical application of fluoride varnish |
2,304 |
1,829 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
856 |
374 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,219 |
944 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,129 |
418 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
610 |
333 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
749 |
334 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,634 |
1,260 |
$20K |
| D1351 |
Sealant - per tooth |
1,347 |
331 |
$19K |
| D0240 |
|
1,563 |
767 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,016 |
818 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
917 |
685 |
$11K |
| D0330 |
Panoramic radiographic image |
331 |
273 |
$9K |
| D0274 |
Bitewings - four radiographic images |
436 |
362 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
194 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,374 |
898 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,548 |
753 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
146 |
74 |
$4K |
| D1354 |
|
441 |
131 |
$4K |
| D9248 |
|
56 |
40 |
$3K |
| D2330 |
|
56 |
28 |
$2K |
| D2331 |
|
31 |
16 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$205.00 |
| D0601 |
|
16 |
16 |
$80.00 |