| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,121 |
1,120 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
952 |
951 |
$25K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
216 |
75 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
629 |
628 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
76 |
$10K |
| D1351 |
Sealant - per tooth |
327 |
111 |
$10K |
| D0272 |
Bitewings - two radiographic images |
497 |
497 |
$9K |
| D1206 |
Topical application of fluoride varnish |
418 |
418 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
246 |
232 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
162 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
38 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
26 |
$4K |
| D1354 |
|
1,995 |
444 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
110 |
$4K |
| D0240 |
|
214 |
112 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
248 |
234 |
$3K |
| D0603 |
|
174 |
174 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$780.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
39 |
$729.00 |
| D9920 |
|
51 |
51 |
$480.00 |
| D1310 |
|
192 |
192 |
$30.00 |
| D1330 |
|
191 |
191 |
$10.00 |
| D9986 |
|
12 |
12 |
$0.00 |