| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,101 |
1,101 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,220 |
1,191 |
$29K |
| D1354 |
|
1,619 |
353 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
857 |
857 |
$20K |
| D1351 |
Sealant - per tooth |
535 |
146 |
$18K |
| D0240 |
|
375 |
375 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
103 |
63 |
$8K |
| D0272 |
Bitewings - two radiographic images |
572 |
572 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
311 |
$7K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
58 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
108 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
53 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
28 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
244 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
154 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
36 |
36 |
$882.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
135 |
135 |
$858.44 |
| D9110 |
|
33 |
32 |
$639.03 |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
71 |
$608.07 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$547.12 |
| D9990 |
|
23 |
23 |
$506.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$450.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$347.62 |