| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,522 |
3,522 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,962 |
3,961 |
$83K |
| D1206 |
Topical application of fluoride varnish |
1,785 |
1,785 |
$40K |
| D1110 |
Prophylaxis - adult |
822 |
821 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,590 |
2,588 |
$31K |
| D1351 |
Sealant - per tooth |
246 |
121 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
136 |
125 |
$13K |
| D0272 |
Bitewings - two radiographic images |
730 |
730 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
280 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
79 |
$4K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
82 |
$874.55 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
13 |
$774.56 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$729.12 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$385.17 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
160 |
150 |
$0.00 |