| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,270 |
3,269 |
$167K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,614 |
1,614 |
$107K |
| D1310 |
|
2,055 |
2,050 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
883 |
883 |
$59K |
| D0145 |
Oral evaluation for a patient under three years of age |
799 |
798 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
730 |
461 |
$48K |
| D1351 |
Sealant - per tooth |
1,228 |
337 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,033 |
975 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,888 |
2,501 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,586 |
1,586 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,487 |
1,487 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,616 |
1,609 |
$19K |
| D0603 |
|
1,112 |
1,111 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
142 |
$10K |
| D0602 |
|
614 |
613 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
159 |
109 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
65 |
46 |
$8K |
| D0350 |
|
764 |
381 |
$7K |
| D0274 |
Bitewings - four radiographic images |
303 |
303 |
$6K |
| D0272 |
Bitewings - two radiographic images |
322 |
322 |
$4K |
| D0601 |
|
141 |
141 |
$2K |
| D9430 |
|
27 |
25 |
$864.00 |
| D1354 |
|
49 |
21 |
$588.00 |