| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,224 |
466 |
$69K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
398 |
181 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
561 |
300 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
692 |
681 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
396 |
263 |
$30K |
| D1120 |
Prophylaxis - child |
795 |
793 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
338 |
252 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
770 |
770 |
$19K |
| D1206 |
Topical application of fluoride varnish |
662 |
661 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
186 |
124 |
$13K |
| D0330 |
Panoramic radiographic image |
216 |
216 |
$10K |
| D0272 |
Bitewings - two radiographic images |
391 |
391 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
284 |
284 |
$6K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$5K |
| D0603 |
|
478 |
478 |
$4K |
| D1330 |
|
625 |
625 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
159 |
$2K |
| D0240 |
|
61 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$215.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$139.27 |