| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,519 |
3,107 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,581 |
2,249 |
$87K |
| D1206 |
Topical application of fluoride varnish |
3,787 |
3,296 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
500 |
200 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,425 |
1,285 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,765 |
1,566 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
194 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,266 |
1,097 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
414 |
363 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,038 |
916 |
$12K |
| D0330 |
Panoramic radiographic image |
162 |
150 |
$7K |
| D1351 |
Sealant - per tooth |
225 |
60 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
26 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
87 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
26 |
$361.01 |
| D1999 |
|
22 |
22 |
$0.00 |