| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,230 |
1,230 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
573 |
$38K |
| D1310 |
|
698 |
698 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
357 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,765 |
950 |
$19K |
| D1206 |
Topical application of fluoride varnish |
496 |
496 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
224 |
121 |
$15K |
| D1351 |
Sealant - per tooth |
384 |
123 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
252 |
234 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
784 |
765 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
130 |
130 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
546 |
546 |
$8K |
| D1320 |
|
633 |
633 |
$6K |
| D9920 |
|
51 |
51 |
$5K |
| D0603 |
|
357 |
357 |
$5K |
| D0350 |
|
578 |
223 |
$5K |
| D0602 |
|
190 |
190 |
$3K |
| D0272 |
Bitewings - two radiographic images |
210 |
209 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
33 |
$2K |
| D1354 |
|
175 |
63 |
$2K |
| D9430 |
|
59 |
57 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
13 |
$1K |