| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,834 |
2,822 |
$191K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
372 |
262 |
$177K |
| D1120 |
Prophylaxis - child |
3,791 |
3,772 |
$162K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,380 |
2,372 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,217 |
1,244 |
$148K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,241 |
321 |
$148K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,921 |
4,776 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,990 |
4,967 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
1,560 |
1,559 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,214 |
672 |
$66K |
| D1310 |
|
1,264 |
1,255 |
$57K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
351 |
97 |
$35K |
| D4341 |
|
463 |
152 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
791 |
772 |
$32K |
| D1110 |
Prophylaxis - adult |
343 |
343 |
$30K |
| D0350 |
|
2,549 |
1,209 |
$24K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
51 |
42 |
$24K |
| D9430 |
|
722 |
701 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
327 |
139 |
$21K |
| D9993 |
|
322 |
320 |
$20K |
| D2954 |
|
192 |
143 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,628 |
1,560 |
$19K |
| D0603 |
|
1,234 |
1,226 |
$18K |
| D0274 |
Bitewings - four radiographic images |
864 |
864 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,462 |
1,456 |
$17K |
| D4910 |
|
214 |
214 |
$16K |
| D1351 |
Sealant - per tooth |
447 |
135 |
$13K |
| D2140 |
|
220 |
77 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
60 |
$7K |
| D3320 |
|
15 |
12 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$2K |
| D2330 |
|
20 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |