| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,213 |
950 |
$224K |
| D1351 |
Sealant - per tooth |
7,882 |
1,490 |
$165K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,031 |
525 |
$72K |
| D1120 |
Prophylaxis - child |
2,250 |
2,223 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,960 |
1,768 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,454 |
2,423 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
590 |
356 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,519 |
1,511 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
646 |
362 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
459 |
274 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
874 |
845 |
$19K |
| D9310 |
|
657 |
650 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,239 |
1,217 |
$15K |
| D0330 |
Panoramic radiographic image |
665 |
653 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
217 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
789 |
755 |
$7K |
| D0240 |
|
405 |
292 |
$6K |
| D1510 |
|
42 |
32 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
435 |
220 |
$4K |
| D1354 |
|
210 |
56 |
$608.60 |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
26 |
$602.66 |
| D0170 |
|
14 |
13 |
$358.26 |
| D1999 |
|
1,624 |
1,182 |
$0.00 |
| D0603 |
|
109 |
108 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |