| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,333 |
2,333 |
$120K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
865 |
368 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,524 |
726 |
$102K |
| D1351 |
Sealant - per tooth |
2,164 |
593 |
$82K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
795 |
339 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,174 |
1,173 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
968 |
968 |
$61K |
| D1310 |
|
1,218 |
1,218 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,333 |
2,333 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,009 |
957 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
677 |
375 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,765 |
1,841 |
$36K |
| D1510 |
|
100 |
74 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
247 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
256 |
256 |
$16K |
| D0603 |
|
990 |
990 |
$15K |
| D2332 |
|
174 |
123 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
159 |
120 |
$13K |
| D9430 |
|
380 |
362 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
860 |
847 |
$10K |
| D0274 |
Bitewings - four radiographic images |
457 |
457 |
$9K |
| D0272 |
Bitewings - two radiographic images |
615 |
615 |
$7K |
| D1517 |
|
12 |
12 |
$4K |
| D0602 |
|
163 |
163 |
$2K |
| D0350 |
|
268 |
140 |
$2K |