| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,073 |
4,025 |
$231K |
| D7961 |
|
726 |
682 |
$113K |
| D7962 |
|
642 |
604 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,222 |
3,172 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,154 |
432 |
$81K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
656 |
233 |
$79K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,057 |
464 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,682 |
3,665 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,794 |
1,788 |
$48K |
| D0330 |
Panoramic radiographic image |
949 |
938 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
746 |
356 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,982 |
1,967 |
$38K |
| D1110 |
Prophylaxis - adult |
464 |
455 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
655 |
633 |
$25K |
| D1351 |
Sealant - per tooth |
796 |
227 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,515 |
1,480 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
374 |
365 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
817 |
778 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,171 |
1,067 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
106 |
45 |
$7K |
| D0274 |
Bitewings - four radiographic images |
111 |
110 |
$4K |
| D7111 |
|
36 |
17 |
$2K |
| D9420 |
|
31 |
31 |
$676.00 |