| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,504 |
1,500 |
$56K |
| D9248 |
|
286 |
272 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,386 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
331 |
147 |
$42K |
| D1351 |
Sealant - per tooth |
1,226 |
210 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
415 |
213 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
166 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,163 |
1,161 |
$27K |
| D1110 |
Prophylaxis - adult |
479 |
479 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
569 |
566 |
$20K |
| D1206 |
Topical application of fluoride varnish |
814 |
813 |
$17K |
| D0272 |
Bitewings - two radiographic images |
697 |
694 |
$15K |
| D1330 |
|
1,723 |
1,720 |
$14K |
| D0603 |
|
1,464 |
1,461 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
233 |
217 |
$11K |
| D1310 |
|
627 |
626 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
664 |
651 |
$8K |
| D0274 |
Bitewings - four radiographic images |
152 |
152 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
111 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
485 |
459 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
30 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1320 |
|
140 |
140 |
$2K |
| D9110 |
|
14 |
14 |
$552.00 |
| D8660 |
|
14 |
14 |
$536.00 |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$440.88 |
| D0340 |
|
13 |
13 |
$408.29 |
| D0350 |
|
14 |
14 |
$0.00 |