| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
558 |
470 |
$22K |
| D1206 |
Topical application of fluoride varnish |
468 |
424 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
178 |
$5K |
| D0272 |
Bitewings - two radiographic images |
326 |
272 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
204 |
160 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
99 |
$3K |
| D9248 |
|
50 |
33 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
189 |
141 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
36 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
43 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
15 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
27 |
$1K |
| D0602 |
|
579 |
447 |
$1K |
| D0603 |
|
149 |
134 |
$470.00 |
| D0191 |
|
39 |
37 |
$348.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
25 |
$245.76 |
| D0240 |
|
15 |
13 |
$183.82 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
16 |
$106.91 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$58.90 |
| D1330 |
|
173 |
160 |
$0.00 |