| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,495 |
1,342 |
$55K |
| D1206 |
Topical application of fluoride varnish |
890 |
839 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
231 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,195 |
1,074 |
$17K |
| D9248 |
|
233 |
178 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
447 |
$14K |
| D1351 |
Sealant - per tooth |
712 |
193 |
$11K |
| D0272 |
Bitewings - two radiographic images |
697 |
620 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
281 |
122 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
155 |
68 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
185 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
635 |
482 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
104 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
637 |
523 |
$5K |
| D0330 |
Panoramic radiographic image |
139 |
123 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
166 |
$2K |
| D0274 |
Bitewings - four radiographic images |
45 |
41 |
$895.66 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$768.00 |
| D1353 |
|
31 |
15 |
$459.20 |
| D9215 |
|
237 |
218 |
$276.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
27 |
$141.36 |