| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,159 |
1,159 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
118 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,124 |
1,124 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,268 |
1,244 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,317 |
1,309 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
129 |
38 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
81 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
925 |
925 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
341 |
325 |
$10K |
| D0272 |
Bitewings - two radiographic images |
490 |
490 |
$10K |
| D1110 |
Prophylaxis - adult |
239 |
239 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
46 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
143 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
163 |
163 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$4K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$4K |
| D1206 |
Topical application of fluoride varnish |
217 |
216 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
12 |
$2K |
| D9420 |
|
12 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
12 |
$74.16 |