| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,418 |
3,084 |
$133K |
| D1206 |
Topical application of fluoride varnish |
3,304 |
2,958 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,545 |
2,328 |
$62K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
482 |
76 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,601 |
1,393 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,485 |
1,224 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,059 |
1,289 |
$10K |
| D0603 |
|
2,487 |
2,142 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
208 |
192 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
201 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
280 |
243 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
44 |
$4K |
| D1351 |
Sealant - per tooth |
232 |
55 |
$3K |
| D0602 |
|
463 |
459 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
166 |
$1K |
| D0240 |
|
54 |
29 |
$832.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
15 |
15 |
$510.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$327.39 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$240.00 |
| D1999 |
|
19 |
19 |
$0.00 |
| D1330 |
|
1,973 |
1,640 |
$0.00 |
| D9630 |
|
14 |
14 |
$0.00 |
| D9215 |
|
13 |
13 |
$0.00 |