| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,614 |
1,611 |
$69K |
| D1351 |
Sealant - per tooth |
2,994 |
764 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,722 |
1,721 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,473 |
1,472 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
436 |
238 |
$30K |
| D1353 |
|
1,889 |
437 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
185 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
584 |
578 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
114 |
72 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
158 |
94 |
$10K |
| D0272 |
Bitewings - two radiographic images |
795 |
795 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,397 |
1,394 |
$6K |
| D0603 |
|
643 |
640 |
$5K |
| D0274 |
Bitewings - four radiographic images |
447 |
447 |
$5K |
| D1110 |
Prophylaxis - adult |
122 |
122 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,323 |
1,322 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
71 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
54 |
53 |
$2K |
| D0601 |
|
212 |
212 |
$2K |
| D7111 |
|
19 |
13 |
$855.00 |
| D0602 |
|
35 |
35 |
$250.00 |