| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,239 |
1,239 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,056 |
1,056 |
$22K |
| D0274 |
Bitewings - four radiographic images |
631 |
631 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
987 |
986 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
113 |
57 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
685 |
685 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
61 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
40 |
$5K |
| D1351 |
Sealant - per tooth |
137 |
38 |
$4K |
| D1206 |
Topical application of fluoride varnish |
193 |
193 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
560 |
560 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
44 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
91 |
91 |
$3K |
| D9310 |
|
32 |
32 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$615.15 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$520.58 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$381.31 |
| D1330 |
|
14 |
14 |
$0.00 |
| D1310 |
|
14 |
14 |
$0.00 |