| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,954 |
1,909 |
$48K |
| D1120 |
Prophylaxis - child |
1,106 |
1,085 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,217 |
1,196 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
75 |
12 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
246 |
$10K |
| D0274 |
Bitewings - four radiographic images |
268 |
252 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
116 |
12 |
$10K |
| D1110 |
Prophylaxis - adult |
164 |
160 |
$9K |
| D0330 |
Panoramic radiographic image |
137 |
135 |
$9K |
| D1351 |
Sealant - per tooth |
228 |
26 |
$8K |
| D0272 |
Bitewings - two radiographic images |
110 |
107 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
45 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$504.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$296.80 |
| D1999 |
|
1,562 |
1,450 |
$0.00 |