| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,793 |
756 |
$280K |
| D1120 |
Prophylaxis - child |
8,362 |
8,148 |
$238K |
| D1206 |
Topical application of fluoride varnish |
10,191 |
9,930 |
$202K |
| D0120 |
Periodic oral evaluation - established patient |
7,814 |
7,631 |
$169K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,036 |
909 |
$131K |
| D1354 |
|
5,690 |
1,601 |
$119K |
| D2934 |
|
736 |
235 |
$108K |
| D1351 |
Sealant - per tooth |
3,497 |
872 |
$78K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,854 |
1,747 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,291 |
849 |
$71K |
| D0272 |
Bitewings - two radiographic images |
4,678 |
4,522 |
$69K |
| D1310 |
|
6,854 |
6,766 |
$64K |
| D1110 |
Prophylaxis - adult |
1,561 |
1,528 |
$62K |
| D1330 |
|
9,659 |
9,396 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
645 |
$57K |
| D0330 |
Panoramic radiographic image |
1,157 |
1,125 |
$42K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
555 |
348 |
$40K |
| D9920 |
|
658 |
640 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,555 |
1,512 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
677 |
644 |
$28K |
| D0240 |
|
1,985 |
1,534 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,510 |
2,336 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,644 |
1,000 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
583 |
579 |
$12K |
| D0274 |
Bitewings - four radiographic images |
199 |
193 |
$5K |
| D0270 |
|
505 |
489 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$3K |
| D2330 |
|
38 |
26 |
$2K |
| D9248 |
|
24 |
24 |
$2K |
| D0603 |
|
407 |
400 |
$2K |
| D0170 |
|
63 |
59 |
$656.25 |
| D0602 |
|
176 |
174 |
$592.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$257.53 |
| D2940 |
|
20 |
17 |
$0.00 |
| D2941 |
|
67 |
47 |
$0.00 |
| D0171 |
|
140 |
138 |
$0.00 |