| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
701 |
230 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
884 |
368 |
$104K |
| D1120 |
Prophylaxis - child |
1,341 |
1,330 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,521 |
1,507 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,624 |
1,611 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
363 |
159 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
448 |
442 |
$30K |
| D1351 |
Sealant - per tooth |
755 |
197 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
172 |
$26K |
| D0272 |
Bitewings - two radiographic images |
887 |
880 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
307 |
$12K |
| D1110 |
Prophylaxis - adult |
209 |
209 |
$11K |
| D1330 |
|
987 |
975 |
$11K |
| D1310 |
|
988 |
976 |
$11K |
| D0240 |
|
259 |
258 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
58 |
28 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
315 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
190 |
189 |
$3K |