| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,665 |
1,654 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,881 |
1,869 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
115 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
1,604 |
1,596 |
$8K |
| D0272 |
Bitewings - two radiographic images |
1,566 |
1,544 |
$7K |
| D1351 |
Sealant - per tooth |
282 |
76 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$1K |
| D1999 |
|
346 |
333 |
$1K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$853.43 |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
206 |
$678.12 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
14 |
$591.02 |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$538.23 |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$446.70 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
43 |
$405.42 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$208.25 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$159.01 |
| D0240 |
|
14 |
13 |
$15.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$11.25 |