| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,452 |
13,452 |
$595K |
| D0120 |
Periodic oral evaluation - established patient |
19,081 |
19,079 |
$571K |
| D1110 |
Prophylaxis - adult |
6,951 |
6,950 |
$407K |
| D9990 |
|
17,637 |
15,836 |
$353K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,751 |
1,452 |
$330K |
| D1351 |
Sealant - per tooth |
6,222 |
2,061 |
$275K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,756 |
14,755 |
$214K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,806 |
2,167 |
$190K |
| D1206 |
Topical application of fluoride varnish |
5,704 |
5,702 |
$158K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,728 |
1,304 |
$148K |
| D0272 |
Bitewings - two radiographic images |
7,279 |
7,277 |
$127K |
| D0274 |
Bitewings - four radiographic images |
4,107 |
4,106 |
$122K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,301 |
785 |
$117K |
| D0330 |
Panoramic radiographic image |
2,068 |
2,068 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
957 |
675 |
$81K |
| D9991 |
|
7,775 |
6,931 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
5,328 |
5,304 |
$75K |
| D2140 |
|
1,210 |
977 |
$67K |
| D2160 |
|
568 |
464 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,379 |
1,379 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,785 |
3,782 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
832 |
735 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
973 |
964 |
$21K |
| D0240 |
|
1,082 |
1,080 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
269 |
225 |
$15K |
| D9110 |
|
491 |
488 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
878 |
863 |
$12K |
| D1510 |
|
94 |
77 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
68 |
$9K |
| D1320 |
|
566 |
566 |
$5K |
| D2335 |
|
26 |
16 |
$4K |
| D9310 |
|
53 |
53 |
$3K |
| D9430 |
|
25 |
25 |
$533.42 |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$474.50 |
| D0160 |
|
14 |
14 |
$446.60 |