| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
875 |
875 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
491 |
491 |
$32K |
| D0350 |
|
3,216 |
837 |
$29K |
| D1310 |
|
616 |
616 |
$27K |
| D1351 |
Sealant - per tooth |
653 |
191 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
259 |
130 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
408 |
357 |
$16K |
| D1206 |
Topical application of fluoride varnish |
553 |
553 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,319 |
655 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
188 |
188 |
$11K |
| D2140 |
|
187 |
99 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$10K |
| D0603 |
|
607 |
607 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
72 |
41 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
88 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
72 |
41 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
518 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
344 |
344 |
$4K |
| D9920 |
|
26 |
24 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
36 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D2330 |
|
24 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$1K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$1K |
| D1320 |
|
52 |
52 |
$615.00 |