| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,784 |
1,631 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,753 |
1,608 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,971 |
1,806 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
116 |
44 |
$17K |
| D1351 |
Sealant - per tooth |
473 |
139 |
$13K |
| D1110 |
Prophylaxis - adult |
350 |
330 |
$13K |
| D0272 |
Bitewings - two radiographic images |
703 |
658 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
265 |
248 |
$11K |
| D1354 |
|
1,458 |
428 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
210 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
45 |
$6K |
| D0330 |
Panoramic radiographic image |
76 |
75 |
$4K |
| D0240 |
|
218 |
141 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
160 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
68 |
60 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
63 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
57 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$461.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$207.48 |
| D1330 |
|
42 |
42 |
$0.00 |
| D1310 |
|
42 |
42 |
$0.00 |