| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,018 |
2,015 |
$121K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
964 |
349 |
$116K |
| D7140 |
Extraction, erupted tooth or exposed root |
903 |
387 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,439 |
1,438 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,147 |
2,144 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
713 |
391 |
$39K |
| D0330 |
Panoramic radiographic image |
507 |
506 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
731 |
706 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
357 |
188 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
368 |
174 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,042 |
1,040 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
801 |
799 |
$22K |
| D1351 |
Sealant - per tooth |
971 |
373 |
$21K |
| D1354 |
|
1,143 |
391 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
739 |
$9K |
| D2330 |
|
126 |
67 |
$7K |
| D1110 |
Prophylaxis - adult |
108 |
108 |
$6K |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
423 |
260 |
$4K |
| D7111 |
|
37 |
17 |
$3K |
| D1353 |
|
149 |
77 |
$2K |
| D9248 |
|
25 |
25 |
$990.21 |
| D0603 |
|
218 |
213 |
$0.00 |