| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,214 |
3,048 |
$137K |
| D1206 |
Topical application of fluoride varnish |
3,184 |
3,021 |
$118K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,700 |
594 |
$117K |
| D1351 |
Sealant - per tooth |
5,077 |
1,162 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,624 |
700 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,560 |
1,513 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,935 |
1,797 |
$39K |
| D2933 |
|
535 |
125 |
$37K |
| D0330 |
Panoramic radiographic image |
856 |
815 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,480 |
1,403 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,014 |
512 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,874 |
1,379 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,136 |
473 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,503 |
2,576 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
761 |
227 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,903 |
1,714 |
$16K |
| D0272 |
Bitewings - two radiographic images |
894 |
820 |
$13K |
| D1353 |
|
712 |
234 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
255 |
247 |
$8K |
| D9420 |
|
269 |
179 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
79 |
$5K |
| D0603 |
|
968 |
907 |
$4K |
| D0240 |
|
204 |
102 |
$2K |
| D7111 |
|
65 |
40 |
$2K |
| D0350 |
|
236 |
168 |
$1K |
| D9310 |
|
86 |
67 |
$1K |
| D3230 |
|
28 |
12 |
$998.96 |
| D0602 |
|
203 |
201 |
$915.00 |
| D0601 |
|
122 |
122 |
$540.00 |
| D9248 |
|
25 |
12 |
$429.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$71.68 |
| D1330 |
|
344 |
310 |
$0.00 |