| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,146 |
2,103 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,029 |
1,013 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
209 |
52 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,304 |
1,269 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,021 |
997 |
$15K |
| D1206 |
Topical application of fluoride varnish |
1,005 |
993 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
193 |
55 |
$12K |
| D0330 |
Panoramic radiographic image |
250 |
249 |
$11K |
| D0240 |
|
1,304 |
473 |
$10K |
| D1351 |
Sealant - per tooth |
540 |
122 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
66 |
$7K |
| D0272 |
Bitewings - two radiographic images |
764 |
756 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$316.12 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$110.00 |