| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
1,601 |
1,499 |
$24K |
| D1120 |
Prophylaxis - child |
999 |
938 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,449 |
1,366 |
$22K |
| D1110 |
Prophylaxis - adult |
644 |
600 |
$22K |
| D0272 |
Bitewings - two radiographic images |
505 |
474 |
$9K |
| D1351 |
Sealant - per tooth |
324 |
44 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
101 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
86 |
70 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
20 |
15 |
$538.10 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
35 |
$436.47 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
24 |
$229.40 |
| D1999 |
|
19 |
19 |
$0.00 |