| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,934 |
11,934 |
$414K |
| D0120 |
Periodic oral evaluation - established patient |
13,591 |
13,591 |
$317K |
| D1206 |
Topical application of fluoride varnish |
12,407 |
12,407 |
$203K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,846 |
1,118 |
$186K |
| D1110 |
Prophylaxis - adult |
3,720 |
3,720 |
$185K |
| D0272 |
Bitewings - two radiographic images |
9,497 |
9,497 |
$179K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,185 |
4,082 |
$133K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,017 |
355 |
$121K |
| D0220 |
Intraoral - periapical first radiographic image |
8,823 |
8,797 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,391 |
7,238 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
728 |
531 |
$67K |
| D0330 |
Panoramic radiographic image |
1,270 |
1,270 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
612 |
373 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,075 |
3,075 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,213 |
1,213 |
$49K |
| D0145 |
Oral evaluation for a patient under three years of age |
951 |
951 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
717 |
714 |
$27K |
| D1351 |
Sealant - per tooth |
642 |
220 |
$19K |
| D9420 |
|
120 |
120 |
$10K |
| D0240 |
|
202 |
109 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
12 |
12 |
$982.32 |