| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,279 |
2,263 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,893 |
1,882 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
667 |
399 |
$45K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
276 |
68 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
595 |
591 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
725 |
639 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
213 |
61 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,474 |
2,454 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
96 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
97 |
85 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
115 |
$6K |
| D0272 |
Bitewings - two radiographic images |
1,295 |
1,283 |
$5K |
| D1110 |
Prophylaxis - adult |
84 |
81 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
2,069 |
2,001 |
$4K |
| D1330 |
|
2,534 |
2,513 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,702 |
1,567 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
157 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$768.00 |
| D1351 |
Sealant - per tooth |
73 |
25 |
$551.00 |
| D0603 |
|
1,478 |
1,317 |
$377.00 |
| D0601 |
|
841 |
839 |
$254.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
27 |
$112.00 |