| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,214 |
322 |
$134K |
| D1120 |
Prophylaxis - child |
2,962 |
2,959 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
2,111 |
2,108 |
$61K |
| D1206 |
Topical application of fluoride varnish |
2,875 |
2,871 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
533 |
277 |
$41K |
| D1351 |
Sealant - per tooth |
1,027 |
314 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
435 |
198 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,545 |
763 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
550 |
549 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,118 |
1,117 |
$21K |
| D0603 |
|
2,979 |
2,975 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
236 |
126 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
179 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
588 |
570 |
$16K |
| D0240 |
|
895 |
585 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,070 |
1,051 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
390 |
390 |
$11K |
| D2929 |
|
91 |
27 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
257 |
256 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$5K |
| D1510 |
|
33 |
25 |
$4K |
| D0330 |
Panoramic radiographic image |
173 |
172 |
$2K |
| D1354 |
|
723 |
333 |
$1K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$795.95 |
| D0602 |
|
27 |
27 |
$187.00 |
| D1330 |
|
1,498 |
1,496 |
$0.29 |
| D1310 |
|
1,497 |
1,495 |
$0.08 |