| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,257 |
12,257 |
$357K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,202 |
1,002 |
$260K |
| D0120 |
Periodic oral evaluation - established patient |
12,567 |
12,567 |
$256K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,646 |
2,153 |
$240K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,557 |
15,557 |
$227K |
| D1110 |
Prophylaxis - adult |
3,231 |
3,231 |
$142K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,942 |
1,179 |
$125K |
| D0272 |
Bitewings - two radiographic images |
6,792 |
6,792 |
$119K |
| D1354 |
|
4,971 |
1,379 |
$116K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,339 |
4,176 |
$114K |
| D0220 |
Intraoral - periapical first radiographic image |
7,492 |
7,481 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,065 |
786 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,306 |
7,147 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
1,508 |
1,504 |
$44K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,283 |
1,283 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,148 |
1,148 |
$34K |
| D9310 |
|
409 |
409 |
$19K |
| D1510 |
|
145 |
132 |
$17K |
| D1351 |
Sealant - per tooth |
442 |
124 |
$10K |
| D2330 |
|
166 |
58 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
68 |
62 |
$6K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$5K |
| D9248 |
|
30 |
30 |
$4K |
| D3120 |
|
16 |
12 |
$488.00 |