| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,560 |
381 |
$69K |
| D1120 |
Prophylaxis - child |
1,705 |
1,672 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,981 |
1,949 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
463 |
264 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
230 |
98 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,215 |
2,176 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,197 |
1,170 |
$26K |
| D1110 |
Prophylaxis - adult |
454 |
448 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
129 |
129 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,470 |
1,424 |
$16K |
| D0274 |
Bitewings - four radiographic images |
468 |
457 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,447 |
1,206 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
253 |
$9K |
| D0330 |
Panoramic radiographic image |
201 |
197 |
$8K |
| D9248 |
|
59 |
52 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
205 |
198 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
32 |
31 |
$411.60 |
| D0603 |
|
2,154 |
2,125 |
$0.00 |
| D0602 |
|
389 |
386 |
$0.00 |
| D9219 |
|
138 |
123 |
$0.00 |
| D1999 |
|
488 |
460 |
$0.00 |
| D9986 |
|
27 |
26 |
$0.00 |