| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,082 |
4,082 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
4,275 |
4,275 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,384 |
2,384 |
$37K |
| D1110 |
Prophylaxis - adult |
1,063 |
1,063 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
381 |
264 |
$14K |
| D0330 |
Panoramic radiographic image |
828 |
828 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,498 |
2,498 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,423 |
1,423 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
312 |
$9K |
| D1351 |
Sealant - per tooth |
309 |
94 |
$4K |
| D0274 |
Bitewings - four radiographic images |
382 |
382 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
62 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
14 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
196 |
196 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
115 |
$653.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
518 |
511 |
$478.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$270.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$8.00 |
| D1310 |
|
26 |
26 |
$0.00 |
| D1330 |
|
15 |
15 |
$0.00 |