| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,759 |
6,758 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
7,755 |
7,754 |
$87K |
| D1206 |
Topical application of fluoride varnish |
4,130 |
4,130 |
$68K |
| D1110 |
Prophylaxis - adult |
2,228 |
2,228 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
835 |
565 |
$44K |
| D1351 |
Sealant - per tooth |
1,468 |
483 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,547 |
4,546 |
$21K |
| D0330 |
Panoramic radiographic image |
1,450 |
1,450 |
$21K |
| D0272 |
Bitewings - two radiographic images |
2,377 |
2,377 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
156 |
58 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
405 |
252 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,097 |
1,097 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
541 |
541 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
715 |
552 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,051 |
1,023 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
340 |
340 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
444 |
444 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
285 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$62.00 |
| D1999 |
|
925 |
908 |
$0.00 |