| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,572 |
511 |
$70K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
442 |
153 |
$64K |
| D1120 |
Prophylaxis - child |
623 |
613 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
773 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
146 |
142 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
69 |
$16K |
| D0272 |
Bitewings - two radiographic images |
567 |
557 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
868 |
854 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
962 |
937 |
$12K |
| D1110 |
Prophylaxis - adult |
189 |
188 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
884 |
866 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
96 |
40 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
234 |
225 |
$6K |
| D9248 |
|
47 |
47 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
59 |
$5K |
| D0274 |
Bitewings - four radiographic images |
123 |
122 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$676.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$551.00 |
| D0603 |
|
498 |
491 |
$0.00 |
| D0602 |
|
484 |
474 |
$0.00 |