| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
737 |
734 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
153 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
544 |
540 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
132 |
45 |
$30K |
| D1206 |
Topical application of fluoride varnish |
745 |
742 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
65 |
$20K |
| D1351 |
Sealant - per tooth |
316 |
128 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
213 |
181 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
499 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
576 |
449 |
$10K |
| D0272 |
Bitewings - two radiographic images |
306 |
303 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
45 |
26 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
167 |
167 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
40 |
$5K |
| D0240 |
|
174 |
89 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$2K |
| D0603 |
|
175 |
175 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$675.00 |
| D1354 |
|
37 |
12 |
$184.00 |
| D1310 |
|
43 |
43 |
$0.00 |
| D1330 |
|
27 |
27 |
$0.00 |