| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,483 |
1,483 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,652 |
1,601 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,424 |
1,424 |
$34K |
| D1354 |
|
1,926 |
411 |
$29K |
| D1351 |
Sealant - per tooth |
614 |
166 |
$22K |
| D1110 |
Prophylaxis - adult |
226 |
226 |
$11K |
| D9990 |
|
480 |
453 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
60 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
750 |
$9K |
| D0272 |
Bitewings - two radiographic images |
533 |
532 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
172 |
157 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
182 |
$5K |
| D0274 |
Bitewings - four radiographic images |
182 |
182 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
58 |
31 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
325 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
621 |
620 |
$4K |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$3K |
| D0240 |
|
110 |
110 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
29 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
90 |
90 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
28 |
$2K |
| D9110 |
|
12 |
12 |
$289.47 |