| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,409 |
409 |
$199K |
| D1120 |
Prophylaxis - child |
1,756 |
1,756 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
376 |
178 |
$54K |
| D2934 |
|
364 |
94 |
$54K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
541 |
215 |
$48K |
| D9420 |
|
409 |
409 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,823 |
1,435 |
$33K |
| D9248 |
|
384 |
372 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,855 |
1,855 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
782 |
779 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,247 |
2,239 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
679 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
625 |
625 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
230 |
230 |
$15K |
| D9920 |
|
263 |
261 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
403 |
390 |
$13K |
| D0272 |
Bitewings - two radiographic images |
568 |
568 |
$11K |
| D1351 |
Sealant - per tooth |
233 |
67 |
$7K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$3K |
| D9310 |
|
26 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$604.80 |