| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8660 |
|
327 |
318 |
$30K |
| D1120 |
Prophylaxis - child |
608 |
603 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
110 |
41 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
869 |
629 |
$12K |
| D1206 |
Topical application of fluoride varnish |
635 |
631 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
275 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
67 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
670 |
659 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
310 |
306 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
221 |
213 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
68 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
70 |
17 |
$5K |
| D0274 |
Bitewings - four radiographic images |
155 |
155 |
$5K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
28 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$635.05 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$555.12 |