| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,227 |
283 |
$168K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,084 |
1,070 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,171 |
468 |
$106K |
| D1351 |
Sealant - per tooth |
3,970 |
771 |
$99K |
| D1120 |
Prophylaxis - child |
2,691 |
2,601 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,094 |
2,004 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,534 |
2,449 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,126 |
1,079 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
3,370 |
3,210 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,233 |
3,001 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
283 |
143 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,460 |
1,423 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,462 |
1,400 |
$19K |
| D0330 |
Panoramic radiographic image |
565 |
531 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
208 |
71 |
$17K |
| D1110 |
Prophylaxis - adult |
346 |
336 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
488 |
454 |
$13K |
| D0274 |
Bitewings - four radiographic images |
365 |
354 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$6K |
| D9248 |
|
43 |
40 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
117 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0603 |
|
4,596 |
4,452 |
$0.00 |
| D0602 |
|
22 |
22 |
$0.00 |