| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,789 |
2,789 |
$92K |
| D1206 |
Topical application of fluoride varnish |
3,365 |
3,365 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
2,263 |
2,263 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,502 |
1,324 |
$46K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
306 |
110 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,737 |
1,737 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
227 |
122 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
472 |
472 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
481 |
479 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,344 |
1,324 |
$17K |
| D1110 |
Prophylaxis - adult |
364 |
364 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
256 |
256 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
909 |
596 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
39 |
$8K |
| D1351 |
Sealant - per tooth |
108 |
36 |
$3K |
| D9310 |
|
47 |
47 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$145.80 |