| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,080 |
1,080 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
169 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
599 |
598 |
$15K |
| D1206 |
Topical application of fluoride varnish |
514 |
514 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
506 |
506 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
553 |
553 |
$7K |
| D1351 |
Sealant - per tooth |
140 |
51 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
447 |
443 |
$6K |
| D0272 |
Bitewings - two radiographic images |
240 |
240 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
39 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
26 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$875.95 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$665.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$612.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
47 |
$309.60 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
196 |
178 |
$0.00 |