| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,748 |
1,727 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
859 |
478 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,729 |
1,709 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,027 |
877 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
678 |
674 |
$10K |
| D0272 |
Bitewings - two radiographic images |
767 |
762 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,633 |
1,034 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
343 |
241 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
548 |
320 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,093 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,146 |
1,126 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
157 |
$5K |
| D1351 |
Sealant - per tooth |
853 |
314 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
95 |
$2K |
| D0274 |
Bitewings - four radiographic images |
100 |
92 |
$538.20 |
| D0140 |
Limited oral evaluation - problem focused |
52 |
52 |
$355.08 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
19 |
$243.13 |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$0.00 |