| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,906 |
4,869 |
$100K |
| D1206 |
Topical application of fluoride varnish |
6,027 |
5,979 |
$77K |
| D9920 |
|
1,752 |
1,674 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
4,951 |
4,913 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,112 |
577 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,482 |
1,358 |
$27K |
| D1110 |
Prophylaxis - adult |
909 |
902 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,917 |
1,897 |
$24K |
| D1351 |
Sealant - per tooth |
1,361 |
433 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
795 |
$13K |
| D0274 |
Bitewings - four radiographic images |
400 |
393 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
240 |
163 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
297 |
166 |
$2K |
| D0330 |
Panoramic radiographic image |
169 |
169 |
$917.83 |
| D0140 |
Limited oral evaluation - problem focused |
230 |
224 |
$871.56 |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
149 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
207 |
84 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$0.00 |
| D9310 |
|
52 |
52 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
51 |
28 |
$0.00 |
| D3120 |
|
17 |
14 |
$0.00 |
| D9994 |
|
284 |
284 |
$0.00 |