| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,622 |
1,614 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,142 |
2,131 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,843 |
1,834 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
217 |
$32K |
| D1110 |
Prophylaxis - adult |
467 |
467 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
534 |
515 |
$17K |
| D9994 |
|
2,167 |
2,156 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
115 |
$15K |
| D0272 |
Bitewings - two radiographic images |
582 |
582 |
$12K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
40 |
$6K |
| D9920 |
|
72 |
72 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
15 |
$4K |
| D0240 |
|
219 |
119 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$570.18 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$451.92 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$261.95 |