| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,589 |
5,490 |
$236K |
| D1206 |
Topical application of fluoride varnish |
6,248 |
5,233 |
$176K |
| D1351 |
Sealant - per tooth |
5,255 |
1,061 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,986 |
2,490 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,585 |
593 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,783 |
813 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
3,068 |
2,590 |
$55K |
| D9248 |
|
863 |
660 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,782 |
719 |
$46K |
| D0272 |
Bitewings - two radiographic images |
3,044 |
2,531 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,445 |
1,196 |
$39K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,013 |
2,137 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
890 |
474 |
$26K |
| D0330 |
Panoramic radiographic image |
825 |
661 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
563 |
246 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
489 |
246 |
$15K |
| D0240 |
|
1,445 |
635 |
$15K |
| D2140 |
|
299 |
128 |
$9K |
| D0274 |
Bitewings - four radiographic images |
323 |
275 |
$6K |
| D2330 |
|
144 |
77 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
682 |
525 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
49 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
444 |
336 |
$3K |
| D3120 |
|
385 |
190 |
$3K |
| D1510 |
|
37 |
26 |
$3K |
| D2331 |
|
53 |
24 |
$3K |
| D1353 |
|
177 |
63 |
$2K |
| D2332 |
|
15 |
12 |
$830.30 |
| D1354 |
|
54 |
14 |
$381.30 |
| D0170 |
|
16 |
16 |
$258.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
15 |
$100.13 |
| D9215 |
|
210 |
81 |
$6.15 |