| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,078 |
446 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
3,663 |
3,431 |
$46K |
| D1110 |
Prophylaxis - adult |
1,598 |
1,516 |
$45K |
| D1120 |
Prophylaxis - child |
2,490 |
2,316 |
$45K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
574 |
259 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,088 |
524 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,163 |
636 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,190 |
3,064 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,641 |
1,478 |
$28K |
| D0330 |
Panoramic radiographic image |
626 |
560 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,720 |
1,632 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
513 |
329 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
957 |
868 |
$18K |
| D1206 |
Topical application of fluoride varnish |
692 |
579 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
499 |
243 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
242 |
115 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
352 |
$6K |
| D0274 |
Bitewings - four radiographic images |
131 |
112 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
640 |
588 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
17 |
$730.01 |
| D2332 |
|
21 |
13 |
$557.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
16 |
$213.00 |
| D2330 |
|
20 |
12 |
$158.36 |