| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,532 |
6,528 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
9,147 |
9,143 |
$89K |
| D1110 |
Prophylaxis - adult |
3,790 |
3,790 |
$86K |
| D1206 |
Topical application of fluoride varnish |
5,025 |
5,024 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,849 |
4,846 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
685 |
474 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
228 |
70 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
878 |
639 |
$17K |
| D0330 |
Panoramic radiographic image |
1,392 |
1,392 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
401 |
231 |
$13K |
| D0272 |
Bitewings - two radiographic images |
2,019 |
2,019 |
$9K |
| D9997 |
|
232 |
232 |
$8K |
| D1351 |
Sealant - per tooth |
825 |
272 |
$6K |
| D0274 |
Bitewings - four radiographic images |
906 |
905 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
322 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
415 |
415 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
13 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
419 |
419 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
16 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
877 |
856 |
$570.00 |
| D9310 |
|
23 |
23 |
$551.00 |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
142 |
$488.60 |
| D8660 |
|
13 |
13 |
$377.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
27 |
$41.30 |
| D9995 |
|
13 |
13 |
$0.00 |
| D1999 |
|
681 |
671 |
$0.00 |