| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
993 |
988 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
163 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
109 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
259 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
1,023 |
1,017 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
44 |
$4K |
| D0272 |
Bitewings - two radiographic images |
761 |
755 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,030 |
1,023 |
$3K |
| D1351 |
Sealant - per tooth |
434 |
118 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
61 |
$2K |
| D9248 |
|
70 |
64 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
17 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
451 |
446 |
$1K |
| D1206 |
Topical application of fluoride varnish |
167 |
167 |
$1K |
| D1110 |
Prophylaxis - adult |
185 |
182 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
486 |
331 |
$936.30 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
208 |
181 |
$917.90 |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$541.62 |
| D0140 |
Limited oral evaluation - problem focused |
67 |
58 |
$454.60 |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$316.25 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$123.57 |
| D0603 |
|
24 |
24 |
$0.00 |