| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,821 |
782 |
$363K |
| D1120 |
Prophylaxis - child |
8,147 |
8,147 |
$285K |
| D0120 |
Periodic oral evaluation - established patient |
7,715 |
7,715 |
$180K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,960 |
10,960 |
$179K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,704 |
1,121 |
$177K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,631 |
3,583 |
$118K |
| D0272 |
Bitewings - two radiographic images |
6,064 |
6,064 |
$115K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,047 |
512 |
$105K |
| D1110 |
Prophylaxis - adult |
2,029 |
2,029 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,000 |
2,000 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
4,081 |
4,071 |
$52K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
608 |
235 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,418 |
1,418 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,550 |
1,896 |
$38K |
| D0240 |
|
1,786 |
1,748 |
$34K |
| D9248 |
|
290 |
288 |
$19K |
| D0330 |
Panoramic radiographic image |
423 |
423 |
$18K |
| D1351 |
Sealant - per tooth |
406 |
149 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
81 |
$11K |
| D9420 |
|
94 |
94 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
118 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
115 |
115 |
$4K |
| D9310 |
|
65 |
65 |
$4K |