| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,785 |
4,785 |
$226K |
| D0120 |
Periodic oral evaluation - established patient |
5,873 |
5,873 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,887 |
1,150 |
$182K |
| D1351 |
Sealant - per tooth |
3,104 |
990 |
$174K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
881 |
662 |
$120K |
| D1110 |
Prophylaxis - adult |
1,759 |
1,759 |
$112K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
908 |
679 |
$93K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,425 |
4,425 |
$68K |
| D0220 |
Intraoral - periapical first radiographic image |
4,309 |
4,303 |
$66K |
| D1206 |
Topical application of fluoride varnish |
2,142 |
2,138 |
$64K |
| D0272 |
Bitewings - two radiographic images |
2,705 |
2,704 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,545 |
1,545 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
725 |
561 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,941 |
3,941 |
$32K |
| D0160 |
|
654 |
654 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
173 |
147 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
364 |
270 |
$19K |
| D1320 |
|
1,668 |
1,667 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
377 |
365 |
$11K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
63 |
53 |
$7K |
| D0601 |
|
116 |
116 |
$0.00 |
| D0603 |
|
27 |
27 |
$0.00 |
| D0602 |
|
76 |
76 |
$0.00 |