| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,206 |
5,206 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
4,510 |
4,510 |
$104K |
| D1206 |
Topical application of fluoride varnish |
6,014 |
6,014 |
$95K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
670 |
300 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
786 |
510 |
$78K |
| D0272 |
Bitewings - two radiographic images |
3,717 |
3,717 |
$68K |
| D1351 |
Sealant - per tooth |
1,677 |
604 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
582 |
318 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,168 |
1,168 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,321 |
1,253 |
$41K |
| D1110 |
Prophylaxis - adult |
757 |
757 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,709 |
2,676 |
$34K |
| D0330 |
Panoramic radiographic image |
598 |
595 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
217 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,942 |
1,579 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
399 |
399 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
141 |
91 |
$11K |
| D0274 |
Bitewings - four radiographic images |
309 |
309 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
220 |
218 |
$8K |
| D9310 |
|
25 |
25 |
$1K |
| D9420 |
|
15 |
15 |
$1K |
| D9920 |
|
12 |
12 |
$527.39 |