| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,199 |
1,198 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,094 |
1,089 |
$24K |
| D1206 |
Topical application of fluoride varnish |
868 |
867 |
$22K |
| D1351 |
Sealant - per tooth |
464 |
149 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
95 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
769 |
763 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
641 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
283 |
276 |
$6K |
| D1110 |
Prophylaxis - adult |
142 |
141 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
459 |
457 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
21 |
$5K |
| D0272 |
Bitewings - two radiographic images |
340 |
339 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
203 |
203 |
$5K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
21 |
$3K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$993.96 |
| D0145 |
Oral evaluation for a patient under three years of age |
31 |
31 |
$644.00 |