| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,018 |
608 |
$268K |
| D1351 |
Sealant - per tooth |
6,867 |
2,094 |
$177K |
| D1120 |
Prophylaxis - child |
5,024 |
4,868 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
5,842 |
5,669 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,461 |
742 |
$130K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,100 |
628 |
$80K |
| D1110 |
Prophylaxis - adult |
1,542 |
1,502 |
$76K |
| D0145 |
Oral evaluation for a patient under three years of age |
554 |
546 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,722 |
3,640 |
$52K |
| D0330 |
Panoramic radiographic image |
823 |
802 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,750 |
1,716 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,762 |
1,711 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,455 |
1,350 |
$35K |
| D1206 |
Topical application of fluoride varnish |
2,624 |
2,537 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,363 |
2,244 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
333 |
102 |
$24K |
| D0274 |
Bitewings - four radiographic images |
745 |
720 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
954 |
935 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
86 |
$8K |
| D9248 |
|
25 |
24 |
$3K |
| D1354 |
|
116 |
39 |
$1K |
| D2330 |
|
17 |
12 |
$1K |
| D9420 |
|
14 |
12 |
$432.93 |
| D0603 |
|
6,965 |
6,880 |
$0.00 |
| D1353 |
|
796 |
385 |
$0.00 |
| D0350 |
|
27 |
25 |
$0.00 |
| D0251 |
|
12 |
12 |
$0.00 |