| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,736 |
12,693 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
11,530 |
11,464 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,796 |
4,527 |
$7K |
| D1206 |
Topical application of fluoride varnish |
13,012 |
12,930 |
$7K |
| D0272 |
Bitewings - two radiographic images |
8,588 |
8,527 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
949 |
772 |
$3K |
| D1351 |
Sealant - per tooth |
2,263 |
1,154 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
515 |
$983.00 |
| D0603 |
|
5,442 |
5,405 |
$930.72 |
| D0220 |
Intraoral - periapical first radiographic image |
3,717 |
3,646 |
$872.94 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,569 |
2,498 |
$811.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
710 |
593 |
$695.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
628 |
579 |
$625.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
310 |
268 |
$480.00 |
| D9430 |
|
66 |
66 |
$125.00 |
| D0602 |
|
24 |
24 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
205 |
164 |
$0.00 |
| D7961 |
|
126 |
110 |
$0.00 |
| D7962 |
|
148 |
129 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
120 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
161 |
156 |
$0.00 |
| D9920 |
|
30 |
29 |
$0.00 |
| D9995 |
|
51 |
51 |
$0.00 |
| D0240 |
|
12 |
12 |
$0.00 |
| D1999 |
|
2,632 |
2,585 |
$0.00 |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$0.00 |
| D2332 |
|
77 |
68 |
$0.00 |
| D8660 |
|
13 |
13 |
$0.00 |