| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,468 |
11,464 |
$140K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,438 |
448 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
13,251 |
13,248 |
$97K |
| D1206 |
Topical application of fluoride varnish |
5,996 |
5,991 |
$57K |
| D1110 |
Prophylaxis - adult |
3,706 |
3,706 |
$53K |
| D1351 |
Sealant - per tooth |
3,960 |
1,136 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,357 |
839 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,643 |
1,076 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,858 |
8,855 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,692 |
1,289 |
$30K |
| D0330 |
Panoramic radiographic image |
2,684 |
2,683 |
$29K |
| D0272 |
Bitewings - two radiographic images |
4,187 |
4,186 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
165 |
76 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
840 |
840 |
$12K |
| D0274 |
Bitewings - four radiographic images |
1,828 |
1,828 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
976 |
976 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
1,090 |
1,087 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
612 |
610 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,912 |
1,849 |
$1K |
| D9997 |
|
27 |
27 |
$761.54 |
| D0230 |
Intraoral - periapical each additional radiographic image |
202 |
202 |
$485.50 |
| D1999 |
|
1,371 |
1,338 |
$0.00 |
| D9995 |
|
23 |
23 |
$0.00 |