| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,941 |
2,941 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
3,423 |
3,423 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
937 |
613 |
$88K |
| D1351 |
Sealant - per tooth |
1,532 |
468 |
$75K |
| D1110 |
Prophylaxis - adult |
936 |
936 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,487 |
1,485 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
2,498 |
2,486 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,394 |
2,394 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
228 |
170 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,548 |
1,547 |
$29K |
| D0274 |
Bitewings - four radiographic images |
749 |
749 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
346 |
264 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
219 |
167 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
370 |
276 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,208 |
2,207 |
$17K |
| D0160 |
|
436 |
436 |
$14K |
| D1320 |
|
904 |
901 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
147 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
25 |
$3K |
| D9110 |
|
13 |
13 |
$414.70 |