| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,357 |
3,247 |
$127K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
808 |
408 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
3,161 |
3,077 |
$82K |
| D1206 |
Topical application of fluoride varnish |
3,386 |
3,293 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
373 |
197 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,358 |
1,304 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
508 |
482 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
410 |
369 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
863 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
29 |
$3K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
131 |
$961.40 |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
35 |
$726.40 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$495.39 |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$455.70 |