| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,617 |
2,595 |
$153K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,282 |
478 |
$148K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,282 |
525 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,949 |
1,936 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,775 |
2,751 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
859 |
510 |
$47K |
| D0330 |
Panoramic radiographic image |
654 |
641 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
935 |
901 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
430 |
245 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,317 |
1,296 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
951 |
940 |
$25K |
| D1351 |
Sealant - per tooth |
1,210 |
447 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
385 |
172 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
932 |
909 |
$11K |
| D1110 |
Prophylaxis - adult |
175 |
174 |
$10K |
| D1354 |
|
662 |
251 |
$8K |
| D2330 |
|
119 |
77 |
$6K |
| D0274 |
Bitewings - four radiographic images |
164 |
160 |
$6K |
| D9248 |
|
99 |
84 |
$5K |
| D2929 |
|
42 |
14 |
$5K |
| D1353 |
|
322 |
138 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
328 |
$5K |
| D2332 |
|
43 |
17 |
$2K |
| D7111 |
|
20 |
16 |
$1K |
| D0603 |
|
152 |
149 |
$0.00 |