| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
715 |
713 |
$12K |
| D1206 |
Topical application of fluoride varnish |
801 |
799 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
554 |
552 |
$9K |
| D0603 |
|
839 |
837 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
15 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
27 |
$5K |
| D1330 |
|
817 |
815 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
164 |
53 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
147 |
139 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
949 |
317 |
$3K |
| D0240 |
|
340 |
196 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
364 |
$2K |
| D9920 |
|
24 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
110 |
110 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
48 |
48 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$979.08 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$582.27 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$322.44 |
| D3120 |
|
57 |
27 |
$246.30 |