| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,742 |
12,613 |
$352K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,681 |
629 |
$350K |
| D1206 |
Topical application of fluoride varnish |
14,162 |
14,021 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
12,363 |
12,233 |
$201K |
| D0272 |
Bitewings - two radiographic images |
5,515 |
5,474 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,964 |
1,905 |
$57K |
| D1110 |
Prophylaxis - adult |
1,488 |
1,483 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,838 |
1,829 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
423 |
$52K |
| D0240 |
|
2,791 |
1,530 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
262 |
129 |
$20K |
| D1351 |
Sealant - per tooth |
643 |
210 |
$18K |
| D0330 |
Panoramic radiographic image |
394 |
394 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,013 |
997 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
241 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
404 |
254 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
46 |
$4K |
| D9630 |
|
130 |
130 |
$3K |
| D9310 |
|
31 |
31 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$861.12 |