| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,171 |
2,171 |
$98K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
631 |
387 |
$63K |
| D1206 |
Topical application of fluoride varnish |
1,476 |
1,476 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,522 |
1,522 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
548 |
315 |
$38K |
| D1351 |
Sealant - per tooth |
1,438 |
363 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
591 |
590 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
956 |
886 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
273 |
188 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
190 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
674 |
674 |
$17K |
| D0603 |
|
1,458 |
1,458 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,219 |
1,219 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
206 |
129 |
$10K |
| D9920 |
|
403 |
393 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,147 |
1,138 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,031 |
1,031 |
$3K |
| D2332 |
|
42 |
29 |
$3K |
| D2335 |
|
18 |
13 |
$2K |
| D0240 |
|
55 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
60 |
$700.00 |