| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,441 |
597 |
$313K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,082 |
956 |
$226K |
| D1120 |
Prophylaxis - child |
8,929 |
5,775 |
$159K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,219 |
3,175 |
$131K |
| D1206 |
Topical application of fluoride varnish |
4,778 |
4,030 |
$98K |
| D7140 |
Extraction, erupted tooth or exposed root |
898 |
489 |
$72K |
| D1351 |
Sealant - per tooth |
2,110 |
341 |
$56K |
| D0272 |
Bitewings - two radiographic images |
5,793 |
3,265 |
$56K |
| D0330 |
Panoramic radiographic image |
1,586 |
1,260 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
604 |
347 |
$49K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,360 |
1,299 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
5,407 |
2,074 |
$44K |
| D2934 |
|
248 |
69 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,003 |
1,647 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
267 |
142 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
548 |
528 |
$21K |
| D0274 |
Bitewings - four radiographic images |
775 |
709 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,480 |
1,290 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
434 |
429 |
$16K |
| D9248 |
|
305 |
301 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
201 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,122 |
987 |
$12K |
| D0603 |
|
3,227 |
2,099 |
$0.00 |