| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,521 |
1,425 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,384 |
1,301 |
$44K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
834 |
179 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,471 |
1,390 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
493 |
201 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
605 |
558 |
$17K |
| D9248 |
|
212 |
183 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
451 |
134 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
1,000 |
951 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
399 |
202 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,820 |
1,725 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,708 |
1,614 |
$9K |
| D9310 |
|
265 |
246 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
612 |
539 |
$6K |
| D2933 |
|
117 |
13 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
73 |
$5K |
| D0330 |
Panoramic radiographic image |
119 |
114 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
118 |
$4K |
| D3230 |
|
103 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
52 |
15 |
$768.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
68 |
$645.12 |