| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,226 |
2,224 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
670 |
261 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,647 |
1,646 |
$44K |
| D1351 |
Sealant - per tooth |
894 |
251 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,256 |
1,253 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
516 |
$19K |
| D0272 |
Bitewings - two radiographic images |
993 |
991 |
$18K |
| D1206 |
Topical application of fluoride varnish |
949 |
949 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
204 |
89 |
$15K |
| D0240 |
|
887 |
455 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
145 |
46 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
345 |
320 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
243 |
$8K |
| D0603 |
|
523 |
522 |
$5K |
| D1354 |
|
1,007 |
297 |
$4K |
| D1999 |
|
496 |
469 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
58 |
29 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
30 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
137 |
$2K |
| D0601 |
|
89 |
89 |
$851.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$678.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$344.00 |
| D1330 |
|
17 |
17 |
$0.00 |