| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,398 |
1,387 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,351 |
1,343 |
$30K |
| D1351 |
Sealant - per tooth |
820 |
239 |
$28K |
| D1110 |
Prophylaxis - adult |
460 |
455 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
463 |
$18K |
| D0330 |
Panoramic radiographic image |
352 |
343 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
531 |
522 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,301 |
1,288 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
470 |
435 |
$14K |
| D0274 |
Bitewings - four radiographic images |
452 |
447 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
83 |
41 |
$10K |
| D1206 |
Topical application of fluoride varnish |
517 |
515 |
$8K |
| D0272 |
Bitewings - two radiographic images |
413 |
407 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
683 |
666 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
45 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
49 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$401.31 |