| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
847 |
843 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
414 |
86 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
182 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
737 |
734 |
$7K |
| D1206 |
Topical application of fluoride varnish |
876 |
872 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
245 |
105 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
250 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
32 |
$4K |
| D1354 |
|
172 |
40 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
39 |
$2K |
| D1351 |
Sealant - per tooth |
293 |
86 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
319 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
47 |
47 |
$940.00 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
47 |
$709.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
180 |
$246.00 |
| D0272 |
Bitewings - two radiographic images |
697 |
689 |
$213.00 |
| D1330 |
|
891 |
887 |
$74.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
52 |
27 |
$0.00 |
| D9420 |
|
27 |
26 |
$0.00 |
| D1999 |
|
111 |
109 |
$0.00 |