| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,517 |
3,183 |
$111K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
942 |
458 |
$100K |
| D1206 |
Topical application of fluoride varnish |
4,492 |
4,045 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
3,402 |
3,032 |
$77K |
| D1351 |
Sealant - per tooth |
2,455 |
616 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
701 |
418 |
$48K |
| D0330 |
Panoramic radiographic image |
1,517 |
1,369 |
$43K |
| D1110 |
Prophylaxis - adult |
1,073 |
957 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
689 |
337 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
947 |
876 |
$27K |
| D9248 |
|
276 |
257 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,533 |
1,380 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
757 |
649 |
$20K |
| D0274 |
Bitewings - four radiographic images |
825 |
727 |
$19K |
| D1353 |
|
547 |
146 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
168 |
108 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
849 |
734 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
186 |
129 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
367 |
347 |
$9K |
| D1510 |
|
52 |
44 |
$8K |
| D2929 |
|
31 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
455 |
84 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
39 |
$849.49 |
| D1354 |
|
30 |
13 |
$297.88 |