| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
935 |
339 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
538 |
309 |
$75K |
| D1120 |
Prophylaxis - child |
1,316 |
1,286 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
346 |
168 |
$37K |
| D2934 |
|
191 |
54 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,788 |
1,746 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,243 |
1,210 |
$27K |
| D7111 |
|
110 |
60 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
261 |
122 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
660 |
605 |
$20K |
| D1351 |
Sealant - per tooth |
575 |
195 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
470 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
111 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
232 |
228 |
$17K |
| D0272 |
Bitewings - two radiographic images |
567 |
558 |
$11K |
| D1110 |
Prophylaxis - adult |
275 |
268 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
647 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
228 |
$8K |
| D9420 |
|
60 |
60 |
$7K |
| D0240 |
|
282 |
277 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
179 |
175 |
$5K |
| D9219 |
|
26 |
26 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
27 |
$873.04 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$819.70 |