| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
929 |
220 |
$131K |
| D1120 |
Prophylaxis - child |
3,427 |
3,427 |
$122K |
| D7140 |
Extraction, erupted tooth or exposed root |
712 |
285 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,820 |
1,820 |
$77K |
| D1206 |
Topical application of fluoride varnish |
3,434 |
3,434 |
$59K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
551 |
204 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,972 |
1,972 |
$49K |
| D9222 |
|
201 |
201 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,526 |
1,526 |
$30K |
| D0145 |
Oral evaluation for a patient under three years of age |
473 |
473 |
$29K |
| D1351 |
Sealant - per tooth |
929 |
303 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
818 |
787 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,323 |
1,036 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
149 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,656 |
1,644 |
$22K |
| D0240 |
|
875 |
479 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
109 |
61 |
$9K |
| D2390 |
|
34 |
12 |
$8K |
| D1110 |
Prophylaxis - adult |
163 |
163 |
$8K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$7K |
| D9310 |
|
76 |
76 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$4K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$571.20 |