| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,089 |
1,086 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,559 |
1,555 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
829 |
828 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
390 |
390 |
$16K |
| D0272 |
Bitewings - two radiographic images |
351 |
349 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
29 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
13 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
127 |
127 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
286 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
25 |
$4K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
89 |
80 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
77 |
$3K |
| D0240 |
|
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$690.82 |