| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,616 |
3,538 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,185 |
3,052 |
$27K |
| D1206 |
Topical application of fluoride varnish |
4,114 |
4,024 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
589 |
144 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
2,729 |
2,682 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,544 |
3,424 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,128 |
1,090 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
451 |
225 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
129 |
$9K |
| D1351 |
Sealant - per tooth |
966 |
273 |
$8K |
| D0274 |
Bitewings - four radiographic images |
651 |
633 |
$6K |
| D1110 |
Prophylaxis - adult |
351 |
341 |
$5K |
| D0272 |
Bitewings - two radiographic images |
812 |
788 |
$5K |
| D0330 |
Panoramic radiographic image |
511 |
493 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
702 |
669 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
309 |
294 |
$4K |
| D0350 |
|
3,713 |
988 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
150 |
$896.13 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
15 |
$553.08 |
| D1354 |
|
36 |
12 |
$315.84 |
| D1330 |
|
1,904 |
1,807 |
$0.00 |