| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,271 |
5,262 |
$158K |
| D0120 |
Periodic oral evaluation - established patient |
7,119 |
7,102 |
$142K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,194 |
7,167 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,501 |
915 |
$89K |
| D1110 |
Prophylaxis - adult |
2,385 |
2,378 |
$87K |
| D1351 |
Sealant - per tooth |
2,437 |
865 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,212 |
1,037 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
486 |
180 |
$46K |
| D0272 |
Bitewings - two radiographic images |
2,128 |
2,116 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
544 |
278 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
502 |
402 |
$24K |
| D1354 |
|
504 |
407 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
616 |
$13K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
635 |
615 |
$5K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
87 |
$2K |
| D0240 |
|
79 |
77 |
$918.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$280.00 |
| D1999 |
|
12 |
12 |
$77.00 |