| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,208 |
9,093 |
$305K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,734 |
751 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,607 |
1,367 |
$193K |
| D1206 |
Topical application of fluoride varnish |
7,609 |
7,547 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
6,071 |
6,011 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,442 |
4,371 |
$129K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,972 |
1,183 |
$121K |
| D1351 |
Sealant - per tooth |
3,569 |
1,083 |
$107K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,523 |
806 |
$89K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,546 |
2,340 |
$73K |
| D0330 |
Panoramic radiographic image |
1,588 |
1,568 |
$65K |
| D1110 |
Prophylaxis - adult |
1,483 |
1,462 |
$61K |
| D9248 |
|
710 |
662 |
$57K |
| D0272 |
Bitewings - two radiographic images |
3,259 |
3,217 |
$54K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
658 |
394 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,031 |
1,967 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,470 |
2,356 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,533 |
976 |
$22K |
| D0274 |
Bitewings - four radiographic images |
741 |
728 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
631 |
617 |
$13K |
| D9110 |
|
142 |
141 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$3K |
| D2330 |
|
44 |
25 |
$3K |
| D1510 |
|
16 |
14 |
$2K |
| D1354 |
|
153 |
72 |
$2K |