| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,898 |
599 |
$209K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,127 |
945 |
$185K |
| D1120 |
Prophylaxis - child |
4,552 |
4,503 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
5,189 |
5,119 |
$108K |
| D1206 |
Topical application of fluoride varnish |
5,439 |
5,371 |
$90K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,405 |
623 |
$84K |
| D0272 |
Bitewings - two radiographic images |
2,326 |
2,302 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,599 |
1,552 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
318 |
143 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,570 |
1,559 |
$23K |
| D1110 |
Prophylaxis - adult |
502 |
500 |
$21K |
| D9310 |
|
438 |
438 |
$21K |
| D1351 |
Sealant - per tooth |
763 |
268 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
167 |
$15K |
| D0240 |
|
571 |
569 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
583 |
229 |
$4K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$366.00 |