| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,046 |
8,982 |
$465K |
| D0120 |
Periodic oral evaluation - established patient |
4,710 |
4,680 |
$327K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,824 |
2,168 |
$324K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,363 |
4,339 |
$292K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,126 |
642 |
$254K |
| D1351 |
Sealant - per tooth |
6,790 |
2,149 |
$251K |
| D2140 |
|
4,091 |
1,880 |
$223K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,385 |
10,316 |
$211K |
| D1310 |
|
4,480 |
4,444 |
$204K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,422 |
1,566 |
$196K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,642 |
508 |
$163K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35,645 |
8,385 |
$154K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,388 |
3,321 |
$135K |
| D0210 |
Intraoral - complete series of radiographic images |
2,083 |
2,076 |
$100K |
| D1110 |
Prophylaxis - adult |
965 |
962 |
$85K |
| D0350 |
|
7,728 |
3,349 |
$82K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,041 |
1,032 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
5,581 |
5,476 |
$67K |
| D2160 |
|
766 |
493 |
$61K |
| D0603 |
|
4,086 |
4,052 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
849 |
544 |
$57K |
| D2330 |
|
694 |
390 |
$54K |
| D9430 |
|
1,255 |
1,205 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
706 |
411 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,251 |
1,244 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,782 |
1,774 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
174 |
$18K |
| D4341 |
|
186 |
48 |
$13K |
| D2331 |
|
152 |
104 |
$12K |
| D2332 |
|
59 |
36 |
$5K |
| D4910 |
|
61 |
61 |
$5K |
| D9993 |
|
72 |
72 |
$5K |
| D1510 |
|
17 |
14 |
$4K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$1K |
| D0602 |
|
61 |
61 |
$915.00 |
| D0270 |
|
15 |
15 |
$75.00 |