| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,340 |
2,250 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,027 |
1,942 |
$65K |
| D1120 |
Prophylaxis - child |
1,705 |
1,643 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
109 |
$23K |
| D0272 |
Bitewings - two radiographic images |
933 |
903 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
667 |
615 |
$16K |
| D9248 |
|
146 |
137 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
37 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
185 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
24 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
62 |
56 |
$3K |
| D1351 |
Sealant - per tooth |
30 |
12 |
$921.51 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$805.00 |