| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,000 |
1,997 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
913 |
912 |
$60K |
| D1310 |
|
1,354 |
1,350 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
745 |
743 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,997 |
1,995 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
560 |
293 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,485 |
1,513 |
$26K |
| D1351 |
Sealant - per tooth |
691 |
202 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
210 |
59 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
362 |
362 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
561 |
498 |
$22K |
| D0603 |
|
1,338 |
1,335 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
255 |
137 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
89 |
30 |
$9K |
| D0272 |
Bitewings - two radiographic images |
730 |
726 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
76 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
538 |
$6K |
| D3240 |
|
50 |
24 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
109 |
$4K |
| D0350 |
|
226 |
87 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$1K |
| D9430 |
|
53 |
53 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$777.60 |