| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
700 |
685 |
$31K |
| D1351 |
Sealant - per tooth |
768 |
170 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
154 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
429 |
414 |
$18K |
| D1206 |
Topical application of fluoride varnish |
436 |
424 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
246 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
40 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
230 |
187 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
181 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
12 |
$4K |
| D0603 |
|
290 |
280 |
$2K |
| D0272 |
Bitewings - two radiographic images |
212 |
198 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
278 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
340 |
244 |
$2K |
| D0601 |
|
106 |
103 |
$1K |
| D0274 |
Bitewings - four radiographic images |
57 |
54 |
$980.00 |
| D0140 |
Limited oral evaluation - problem focused |
20 |
19 |
$775.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$440.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$380.00 |
| D0602 |
|
26 |
26 |
$250.00 |
| D0350 |
|
26 |
26 |
$44.00 |