| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,228 |
1,228 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
671 |
670 |
$44K |
| D1310 |
|
667 |
667 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
437 |
437 |
$29K |
| D1351 |
Sealant - per tooth |
612 |
199 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
318 |
181 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
528 |
450 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,618 |
1,128 |
$19K |
| D1206 |
Topical application of fluoride varnish |
584 |
584 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
556 |
556 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
615 |
$7K |
| D0603 |
|
442 |
442 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
45 |
27 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
44 |
$4K |
| D0350 |
|
407 |
193 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
51 |
$4K |
| D0274 |
Bitewings - four radiographic images |
155 |
155 |
$3K |
| D0272 |
Bitewings - two radiographic images |
185 |
185 |
$2K |
| D0602 |
|
84 |
84 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |