| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
789 |
325 |
$98K |
| D1120 |
Prophylaxis - child |
2,859 |
2,675 |
$94K |
| D0145 |
Oral evaluation for a patient under three years of age |
701 |
671 |
$93K |
| D1351 |
Sealant - per tooth |
3,243 |
586 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
916 |
501 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,882 |
2,705 |
$76K |
| D0210 |
Intraoral - complete series of radiographic images |
772 |
707 |
$46K |
| D1206 |
Topical application of fluoride varnish |
3,023 |
2,815 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,496 |
1,403 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
367 |
143 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
373 |
228 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,292 |
2,088 |
$24K |
| D9248 |
|
229 |
219 |
$22K |
| D1110 |
Prophylaxis - adult |
463 |
425 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
877 |
830 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
441 |
294 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
662 |
592 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,056 |
1,728 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
355 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
251 |
242 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
122 |
$4K |
| D1999 |
|
1,522 |
1,323 |
$0.00 |
| D0603 |
|
4,460 |
4,320 |
$0.00 |