| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,928 |
1,927 |
$83K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
550 |
423 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,522 |
1,521 |
$45K |
| D1351 |
Sealant - per tooth |
1,575 |
345 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,231 |
1,230 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,017 |
878 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
299 |
217 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
523 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
717 |
717 |
$16K |
| D0272 |
Bitewings - two radiographic images |
675 |
675 |
$8K |
| D0602 |
|
790 |
790 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
75 |
45 |
$6K |
| D9920 |
|
242 |
238 |
$6K |
| D0240 |
|
339 |
172 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
39 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
52 |
$5K |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$4K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
400 |
$3K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$2K |
| D0601 |
|
215 |
215 |
$2K |
| D9110 |
|
44 |
44 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
15 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$795.00 |
| D0140 |
Limited oral evaluation - problem focused |
52 |
52 |
$619.00 |
| D9310 |
|
19 |
19 |
$531.62 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
71 |
$270.00 |