| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
4,236 |
3,963 |
$88K |
| D1120 |
Prophylaxis - child |
3,388 |
3,387 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,612 |
2,612 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
761 |
440 |
$55K |
| D1351 |
Sealant - per tooth |
2,313 |
787 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
766 |
504 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,175 |
1,065 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,032 |
2,031 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,048 |
1,048 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,697 |
2,681 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,501 |
2,453 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
40 |
$11K |
| D1110 |
Prophylaxis - adult |
281 |
280 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
211 |
$9K |
| D0330 |
Panoramic radiographic image |
480 |
480 |
$7K |
| D0274 |
Bitewings - four radiographic images |
391 |
391 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$924.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$537.28 |
| D1999 |
|
52 |
51 |
$480.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$414.40 |