| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,139 |
210 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
123 |
37 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
541 |
535 |
$15K |
| D1120 |
Prophylaxis - child |
330 |
326 |
$12K |
| D1110 |
Prophylaxis - adult |
200 |
198 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
120 |
37 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
569 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
670 |
663 |
$8K |
| D0272 |
Bitewings - two radiographic images |
329 |
325 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
647 |
641 |
$7K |
| D0274 |
Bitewings - four radiographic images |
198 |
198 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
26 |
$5K |
| D9248 |
|
30 |
30 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
41 |
$1K |
| D0603 |
|
380 |
377 |
$0.00 |
| D0602 |
|
187 |
185 |
$0.00 |