| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
919 |
737 |
$524K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,486 |
1,741 |
$219K |
| D1120 |
Prophylaxis - child |
4,716 |
4,716 |
$202K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,216 |
937 |
$155K |
| D1110 |
Prophylaxis - adult |
2,682 |
2,682 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
4,145 |
4,145 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,705 |
3,705 |
$111K |
| D1351 |
Sealant - per tooth |
2,152 |
907 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,555 |
1,182 |
$89K |
| D0220 |
Intraoral - periapical first radiographic image |
6,474 |
6,422 |
$86K |
| D1206 |
Topical application of fluoride varnish |
2,270 |
2,269 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
2,049 |
2,037 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,203 |
3,203 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,674 |
2,672 |
$43K |
| D2954 |
|
289 |
255 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
882 |
696 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,222 |
1,166 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
414 |
342 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,248 |
4,244 |
$32K |
| D0274 |
Bitewings - four radiographic images |
731 |
731 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,367 |
1,359 |
$19K |
| D0350 |
|
1,292 |
1,292 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
26 |
24 |
$10K |
| D2332 |
|
79 |
62 |
$9K |
| D0270 |
|
457 |
455 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
40 |
$5K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
25 |
$3K |
| D4342 |
|
47 |
24 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
48 |
48 |
$1K |
| D2330 |
|
15 |
12 |
$817.80 |
| D1354 |
|
30 |
12 |
$450.00 |
| D1999 |
|
462 |
381 |
$0.00 |