| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,597 |
3,121 |
$137K |
| D1206 |
Topical application of fluoride varnish |
3,526 |
3,061 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,003 |
1,738 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
845 |
155 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,696 |
2,333 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,612 |
1,409 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
209 |
$21K |
| D1351 |
Sealant - per tooth |
1,114 |
258 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
551 |
204 |
$17K |
| D0330 |
Panoramic radiographic image |
422 |
378 |
$15K |
| D9248 |
|
130 |
110 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
208 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
82 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
565 |
459 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
467 |
384 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
71 |
$4K |
| D1354 |
|
450 |
81 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
387 |
272 |
$2K |
| D2330 |
|
30 |
12 |
$1K |
| D9420 |
|
39 |
29 |
$1K |
| D9310 |
|
15 |
15 |
$520.00 |
| D3120 |
|
40 |
12 |
$450.00 |
| D0601 |
|
18 |
17 |
$80.00 |
| D0603 |
|
18 |
15 |
$70.00 |
| D0602 |
|
15 |
14 |
$70.00 |