| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,396 |
4,395 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
3,602 |
3,602 |
$105K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
483 |
153 |
$89K |
| D1206 |
Topical application of fluoride varnish |
2,638 |
2,638 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,005 |
1,005 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
303 |
141 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,104 |
1,104 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
145 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,245 |
1,245 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
97 |
60 |
$11K |
| D1351 |
Sealant - per tooth |
121 |
57 |
$7K |
| D9420 |
|
66 |
66 |
$6K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$5K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
16 |
$973.16 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$283.16 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$241.24 |
| D0240 |
|
14 |
14 |
$236.64 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$168.00 |
| D0603 |
|
168 |
167 |
$158.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
231 |
229 |
$60.00 |
| D0601 |
|
49 |
49 |
$48.00 |
| D0190 |
|
18 |
18 |
$0.00 |
| D1330 |
|
78 |
78 |
$0.00 |