| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,896 |
6,896 |
$353K |
| D1351 |
Sealant - per tooth |
8,540 |
2,326 |
$325K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,801 |
4,801 |
$318K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,460 |
778 |
$292K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,790 |
591 |
$176K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,475 |
1,071 |
$166K |
| D1310 |
|
3,611 |
3,611 |
$163K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,820 |
2,763 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,447 |
5,439 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
1,607 |
1,607 |
$95K |
| D1206 |
Topical application of fluoride varnish |
3,063 |
3,063 |
$95K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,444 |
1,444 |
$90K |
| D0210 |
Intraoral - complete series of radiographic images |
1,580 |
1,580 |
$76K |
| D2140 |
|
1,211 |
628 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,049 |
577 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,681 |
3,681 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
2,989 |
2,981 |
$36K |
| D0350 |
|
2,003 |
1,800 |
$35K |
| D0603 |
|
2,361 |
2,361 |
$34K |
| D1320 |
|
1,950 |
1,950 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,580 |
1,580 |
$19K |
| D0274 |
Bitewings - four radiographic images |
682 |
682 |
$15K |
| D0602 |
|
905 |
905 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
61 |
$8K |
| D2330 |
|
46 |
28 |
$4K |
| D2160 |
|
43 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$1K |