| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,338 |
1,335 |
$46K |
| D1120 |
Prophylaxis - child |
1,116 |
1,114 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,035 |
1,034 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
148 |
50 |
$20K |
| D0272 |
Bitewings - two radiographic images |
607 |
606 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
68 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
76 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
284 |
280 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
365 |
$6K |
| D1351 |
Sealant - per tooth |
199 |
57 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
150 |
$2K |
| D9420 |
|
13 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
41 |
41 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$650.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |