| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,215 |
381 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
326 |
115 |
$30K |
| D1120 |
Prophylaxis - child |
1,021 |
940 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,172 |
1,084 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,423 |
1,313 |
$21K |
| D0272 |
Bitewings - two radiographic images |
768 |
696 |
$14K |
| D1110 |
Prophylaxis - adult |
370 |
342 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
87 |
$12K |
| D0274 |
Bitewings - four radiographic images |
380 |
351 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
628 |
313 |
$8K |
| D0330 |
Panoramic radiographic image |
215 |
194 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
53 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
98 |
38 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
30 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
117 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
216 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$812.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
15 |
$410.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
14 |
$126.00 |
| D1330 |
|
1,450 |
1,341 |
$0.00 |
| D0603 |
|
1,141 |
1,049 |
$0.00 |
| D0602 |
|
292 |
274 |
$0.00 |