| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,869 |
1,867 |
$30K |
| D1120 |
Prophylaxis - child |
1,774 |
1,774 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
768 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
431 |
191 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
983 |
983 |
$15K |
| D1351 |
Sealant - per tooth |
1,077 |
223 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
533 |
459 |
$8K |
| D9920 |
|
463 |
460 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
87 |
46 |
$6K |
| D0602 |
|
483 |
483 |
$5K |
| D0603 |
|
475 |
475 |
$5K |
| D0601 |
|
458 |
458 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,100 |
1,092 |
$4K |
| D0272 |
Bitewings - two radiographic images |
731 |
731 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
966 |
966 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
50 |
$3K |
| D0274 |
Bitewings - four radiographic images |
256 |
256 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
33 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
79 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
14 |
$675.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$261.75 |