| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,226 |
4,772 |
$169K |
| D1206 |
Topical application of fluoride varnish |
5,080 |
4,634 |
$126K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
658 |
307 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
4,030 |
3,666 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
849 |
519 |
$83K |
| D1354 |
|
2,823 |
1,059 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
866 |
427 |
$67K |
| D1351 |
Sealant - per tooth |
1,565 |
395 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,212 |
1,006 |
$53K |
| D0330 |
Panoramic radiographic image |
596 |
537 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
822 |
762 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,998 |
1,850 |
$34K |
| D0240 |
|
1,074 |
530 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
420 |
372 |
$15K |
| D1510 |
|
29 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
360 |
312 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$2K |
| D3120 |
|
35 |
13 |
$0.00 |