| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
936 |
935 |
$39K |
| D1206 |
Topical application of fluoride varnish |
963 |
962 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
130 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
617 |
616 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
119 |
80 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$17K |
| D0272 |
Bitewings - two radiographic images |
385 |
385 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
532 |
526 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
55 |
$10K |
| D0240 |
|
430 |
231 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
448 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
53 |
$7K |
| D1351 |
Sealant - per tooth |
200 |
56 |
$6K |
| D9920 |
|
57 |
53 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$870.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$616.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
95 |
78 |
$0.00 |