| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,462 |
1,462 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,063 |
1,062 |
$69K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
526 |
214 |
$61K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
539 |
209 |
$52K |
| D1310 |
|
815 |
814 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
899 |
843 |
$35K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
562 |
272 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,421 |
1,421 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
537 |
259 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,691 |
1,362 |
$27K |
| D1351 |
Sealant - per tooth |
627 |
249 |
$24K |
| D2140 |
|
330 |
162 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
86 |
$11K |
| D0272 |
Bitewings - two radiographic images |
909 |
907 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
222 |
$10K |
| D0350 |
|
921 |
408 |
$9K |
| D0603 |
|
596 |
595 |
$8K |
| D0340 |
|
165 |
165 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
111 |
111 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
175 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
64 |
$6K |
| D0330 |
Panoramic radiographic image |
165 |
165 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
174 |
$2K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$1K |
| D2330 |
|
18 |
12 |
$1K |
| D0602 |
|
54 |
54 |
$795.00 |
| D9430 |
|
14 |
12 |
$448.00 |