| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,272 |
1,269 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
531 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
508 |
224 |
$34K |
| D1310 |
|
760 |
759 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
474 |
473 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,191 |
1,189 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,589 |
889 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
370 |
318 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
199 |
199 |
$13K |
| D0603 |
|
567 |
566 |
$8K |
| D0272 |
Bitewings - two radiographic images |
659 |
658 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
41 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
14 |
$3K |
| D0350 |
|
216 |
105 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
155 |
$2K |
| D0602 |
|
106 |
106 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
14 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D9430 |
|
26 |
25 |
$832.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$470.10 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$105.09 |
| D9310 |
|
12 |
12 |
$0.00 |