| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
534 |
107 |
$81K |
| D1120 |
Prophylaxis - child |
2,212 |
2,071 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,325 |
2,179 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
674 |
349 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,601 |
1,503 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,317 |
1,222 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
714 |
597 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,233 |
1,148 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
453 |
422 |
$22K |
| D1110 |
Prophylaxis - adult |
327 |
306 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
77 |
$15K |
| D0330 |
Panoramic radiographic image |
172 |
162 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
904 |
708 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
62 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
80 |
$4K |
| D9420 |
|
34 |
33 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
138 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
167 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
30 |
12 |
$408.16 |
| D0240 |
|
135 |
71 |
$0.00 |