| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,409 |
1,388 |
$63K |
| D1206 |
Topical application of fluoride varnish |
1,649 |
1,619 |
$58K |
| D1351 |
Sealant - per tooth |
2,482 |
528 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
856 |
352 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
905 |
880 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,598 |
1,717 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
345 |
90 |
$22K |
| D0274 |
Bitewings - four radiographic images |
996 |
966 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
531 |
506 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
559 |
548 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
785 |
760 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
83 |
$8K |
| D0330 |
Panoramic radiographic image |
202 |
201 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
85 |
$5K |
| D9420 |
|
146 |
135 |
$5K |
| D1110 |
Prophylaxis - adult |
88 |
87 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
242 |
205 |
$4K |
| D0603 |
|
594 |
591 |
$3K |
| D9310 |
|
27 |
26 |
$1K |
| D2330 |
|
22 |
12 |
$958.46 |
| D0145 |
Oral evaluation for a patient under three years of age |
41 |
41 |
$877.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$307.32 |
| D0190 |
|
17 |
17 |
$243.78 |