| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,272 |
351 |
$131K |
| D1120 |
Prophylaxis - child |
2,079 |
2,079 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
1,869 |
1,869 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
530 |
522 |
$31K |
| D0272 |
Bitewings - two radiographic images |
955 |
955 |
$26K |
| D1206 |
Topical application of fluoride varnish |
2,054 |
2,054 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,251 |
710 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
263 |
132 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
959 |
957 |
$17K |
| D1351 |
Sealant - per tooth |
194 |
71 |
$9K |
| D2140 |
|
83 |
55 |
$5K |
| D1354 |
|
580 |
127 |
$4K |
| D9310 |
|
37 |
37 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
35 |
35 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
13 |
$1K |