| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,970 |
2,968 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
4,273 |
4,271 |
$111K |
| D1110 |
Prophylaxis - adult |
1,568 |
1,567 |
$75K |
| D1206 |
Topical application of fluoride varnish |
1,958 |
1,957 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
529 |
404 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,925 |
1,924 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
367 |
275 |
$24K |
| D0330 |
Panoramic radiographic image |
650 |
650 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,044 |
1,044 |
$16K |
| D1351 |
Sealant - per tooth |
308 |
88 |
$11K |
| D0274 |
Bitewings - four radiographic images |
273 |
273 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
64 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
138 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
234 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
86 |
$922.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
601 |
597 |
$741.00 |
| D9997 |
|
12 |
12 |
$421.80 |
| D1999 |
|
747 |
730 |
$0.00 |