| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,748 |
1,748 |
$65K |
| D1206 |
Topical application of fluoride varnish |
2,282 |
2,282 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,984 |
1,984 |
$49K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
589 |
564 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
189 |
76 |
$23K |
| D1110 |
Prophylaxis - adult |
512 |
512 |
$23K |
| D0274 |
Bitewings - four radiographic images |
659 |
659 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
279 |
222 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
175 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
445 |
444 |
$11K |
| D0272 |
Bitewings - two radiographic images |
480 |
480 |
$9K |
| D0240 |
|
625 |
325 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
41 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
425 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
156 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
15 |
$1K |
| D1330 |
|
119 |
119 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$900.00 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$696.75 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$647.50 |