| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,203 |
1,190 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,588 |
1,567 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,304 |
1,290 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
394 |
285 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
911 |
821 |
$25K |
| D1110 |
Prophylaxis - adult |
496 |
488 |
$20K |
| D0330 |
Panoramic radiographic image |
429 |
425 |
$18K |
| D0274 |
Bitewings - four radiographic images |
603 |
592 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
251 |
207 |
$15K |
| D0272 |
Bitewings - two radiographic images |
609 |
600 |
$11K |
| D1351 |
Sealant - per tooth |
108 |
42 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
26 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
117 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$292.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
12 |
$167.68 |
| D9986 |
|
245 |
242 |
$0.00 |