| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
415 |
162 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
428 |
245 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
357 |
145 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
281 |
146 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
193 |
$23K |
| D1120 |
Prophylaxis - child |
630 |
630 |
$22K |
| D1110 |
Prophylaxis - adult |
411 |
411 |
$20K |
| D9248 |
|
290 |
271 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
402 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
705 |
705 |
$16K |
| D1206 |
Topical application of fluoride varnish |
919 |
919 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
421 |
396 |
$13K |
| D0274 |
Bitewings - four radiographic images |
427 |
427 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
279 |
278 |
$11K |
| D0272 |
Bitewings - two radiographic images |
523 |
523 |
$10K |
| D1351 |
Sealant - per tooth |
265 |
72 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
478 |
$6K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
131 |
$1K |