| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
348 |
58 |
$15K |
| D1120 |
Prophylaxis - child |
255 |
248 |
$11K |
| D1206 |
Topical application of fluoride varnish |
221 |
215 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
186 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
57 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
173 |
154 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
21 |
15 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$1K |
| D0603 |
|
209 |
171 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
18 |
$965.00 |
| D0251 |
|
31 |
31 |
$754.00 |
| D9920 |
|
17 |
17 |
$700.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$640.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
37 |
$510.00 |
| D0602 |
|
28 |
26 |
$220.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$180.00 |
| D1310 |
|
289 |
172 |
$0.00 |
| D1330 |
|
17 |
16 |
$0.00 |