| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,687 |
5,636 |
$189K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,274 |
545 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,814 |
942 |
$125K |
| D1206 |
Topical application of fluoride varnish |
5,552 |
5,503 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
4,122 |
4,081 |
$97K |
| D9248 |
|
849 |
821 |
$70K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,043 |
507 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,761 |
1,749 |
$51K |
| D1351 |
Sealant - per tooth |
1,844 |
637 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,091 |
2,071 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,086 |
1,059 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
351 |
175 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,453 |
1,408 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
217 |
$17K |
| D0330 |
Panoramic radiographic image |
362 |
358 |
$16K |
| D1354 |
|
1,539 |
382 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
577 |
257 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
41 |
$988.74 |