| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,641 |
1,639 |
$63K |
| D1206 |
Topical application of fluoride varnish |
2,203 |
2,201 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,948 |
1,946 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
547 |
535 |
$30K |
| D1110 |
Prophylaxis - adult |
457 |
457 |
$21K |
| D0274 |
Bitewings - four radiographic images |
599 |
599 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
133 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
76 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
136 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
358 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
27 |
$7K |
| D1351 |
Sealant - per tooth |
206 |
61 |
$7K |
| D0272 |
Bitewings - two radiographic images |
332 |
331 |
$6K |
| D0240 |
|
465 |
246 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
263 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
111 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
61 |
61 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$893.75 |
| D0270 |
|
13 |
13 |
$138.00 |