| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,820 |
1,820 |
$81K |
| D1206 |
Topical application of fluoride varnish |
1,940 |
1,938 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,534 |
1,534 |
$50K |
| D1351 |
Sealant - per tooth |
2,013 |
497 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
305 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
816 |
759 |
$20K |
| D0272 |
Bitewings - two radiographic images |
958 |
958 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
190 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
261 |
167 |
$13K |
| D1353 |
|
1,068 |
231 |
$11K |
| D0603 |
|
1,181 |
1,175 |
$10K |
| D9920 |
|
327 |
310 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
1,028 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
27 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
77 |
77 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
910 |
908 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$3K |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$3K |
| D0240 |
|
86 |
85 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$975.00 |
| D0601 |
|
86 |
86 |
$860.00 |
| D0602 |
|
26 |
26 |
$260.00 |
| D1330 |
|
406 |
392 |
$0.00 |