| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
6,524 |
5,866 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,354 |
931 |
$183K |
| D0120 |
Periodic oral evaluation - established patient |
5,702 |
5,161 |
$162K |
| D1120 |
Prophylaxis - child |
4,666 |
4,199 |
$141K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
617 |
227 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
929 |
502 |
$64K |
| D1351 |
Sealant - per tooth |
2,337 |
679 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,366 |
2,125 |
$47K |
| D1110 |
Prophylaxis - adult |
1,058 |
921 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
920 |
872 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
419 |
224 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
293 |
107 |
$25K |
| D9420 |
|
220 |
179 |
$23K |
| D0330 |
Panoramic radiographic image |
389 |
344 |
$20K |
| D0274 |
Bitewings - four radiographic images |
468 |
418 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
778 |
666 |
$10K |
| D1330 |
|
1,070 |
1,070 |
$10K |
| D1310 |
|
275 |
275 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
61 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
103 |
100 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
53 |
$815.85 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$480.00 |
| D1999 |
|
37 |
37 |
$0.00 |
| D9986 |
|
54 |
41 |
$0.00 |