| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,013 |
1,013 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,053 |
1,053 |
$21K |
| D1351 |
Sealant - per tooth |
715 |
197 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
288 |
176 |
$12K |
| D1206 |
Topical application of fluoride varnish |
738 |
738 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
114 |
$6K |
| D1110 |
Prophylaxis - adult |
155 |
155 |
$6K |
| D0272 |
Bitewings - two radiographic images |
547 |
546 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
397 |
397 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
134 |
84 |
$4K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$3K |
| D1353 |
|
153 |
52 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
26 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
201 |
179 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
322 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$1K |
| D1354 |
|
48 |
13 |
$711.90 |
| D0603 |
|
419 |
419 |
$680.00 |
| D0601 |
|
207 |
207 |
$460.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
145 |
$368.70 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$165.20 |
| D9920 |
|
12 |
12 |
$120.00 |
| D1330 |
|
472 |
472 |
$0.00 |