| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,601 |
3,471 |
$154K |
| D1206 |
Topical application of fluoride varnish |
3,564 |
3,438 |
$120K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,263 |
355 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,310 |
2,206 |
$70K |
| D1351 |
Sealant - per tooth |
2,702 |
536 |
$58K |
| D0272 |
Bitewings - two radiographic images |
2,817 |
2,705 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,005 |
396 |
$44K |
| D9248 |
|
502 |
427 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,441 |
1,412 |
$29K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
782 |
249 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
827 |
295 |
$24K |
| D1354 |
|
1,550 |
398 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
294 |
162 |
$15K |
| D1510 |
|
241 |
116 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,146 |
1,073 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
324 |
311 |
$10K |
| D0330 |
Panoramic radiographic image |
233 |
223 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
986 |
844 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
69 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,057 |
856 |
$6K |
| D0274 |
Bitewings - four radiographic images |
273 |
254 |
$6K |
| D9420 |
|
237 |
135 |
$5K |
| D2933 |
|
73 |
12 |
$5K |
| D9310 |
|
110 |
86 |
$3K |
| D3120 |
|
54 |
13 |
$432.00 |