| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,294 |
1,294 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
962 |
434 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
601 |
347 |
$42K |
| D1206 |
Topical application of fluoride varnish |
920 |
920 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
859 |
859 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
898 |
808 |
$22K |
| D1351 |
Sealant - per tooth |
972 |
280 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
364 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
84 |
69 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
333 |
333 |
$8K |
| D0272 |
Bitewings - two radiographic images |
710 |
710 |
$7K |
| D0330 |
Panoramic radiographic image |
172 |
172 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
79 |
$6K |
| D9920 |
|
229 |
209 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
68 |
$5K |
| D0603 |
|
447 |
447 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
165 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
270 |
$1K |
| D0602 |
|
82 |
82 |
$820.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
124 |
$531.00 |