| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,923 |
4,681 |
$194K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,197 |
889 |
$137K |
| D1206 |
Topical application of fluoride varnish |
4,440 |
4,231 |
$111K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,335 |
2,193 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
3,242 |
3,056 |
$88K |
| D1351 |
Sealant - per tooth |
1,476 |
821 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,234 |
2,110 |
$49K |
| D2140 |
|
990 |
757 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
625 |
477 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,576 |
2,420 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
739 |
719 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
292 |
244 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
242 |
204 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,834 |
2,648 |
$16K |
| D0274 |
Bitewings - four radiographic images |
927 |
889 |
$14K |
| D0330 |
Panoramic radiographic image |
638 |
622 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,347 |
2,170 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$229.44 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$104.00 |
| D1999 |
|
294 |
233 |
$0.00 |