| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,806 |
2,805 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,221 |
1,220 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
1,086 |
1,086 |
$77K |
| D1310 |
|
1,504 |
1,503 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,754 |
2,753 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
704 |
400 |
$46K |
| D1351 |
Sealant - per tooth |
1,139 |
303 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
521 |
521 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
852 |
802 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,690 |
2,204 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,399 |
1,396 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
134 |
106 |
$16K |
| D0603 |
|
711 |
711 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
92 |
75 |
$9K |
| D0602 |
|
545 |
545 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
60 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
54 |
$4K |
| D0274 |
Bitewings - four radiographic images |
175 |
175 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
173 |
172 |
$2K |
| D0350 |
|
319 |
184 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$957.60 |
| D0270 |
|
28 |
28 |
$140.00 |