| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
932 |
372 |
$115K |
| D1351 |
Sealant - per tooth |
2,002 |
487 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
678 |
351 |
$55K |
| D9248 |
|
201 |
201 |
$46K |
| D1120 |
Prophylaxis - child |
1,033 |
1,031 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
677 |
669 |
$37K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
484 |
226 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,277 |
1,271 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
423 |
288 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,311 |
1,309 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
403 |
298 |
$25K |
| D0272 |
Bitewings - two radiographic images |
882 |
881 |
$18K |
| D1110 |
Prophylaxis - adult |
327 |
327 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
136 |
73 |
$13K |
| D0330 |
Panoramic radiographic image |
238 |
238 |
$11K |
| D0603 |
|
891 |
890 |
$9K |
| D0240 |
|
317 |
250 |
$7K |
| D1330 |
|
1,022 |
1,021 |
$5K |
| D0274 |
Bitewings - four radiographic images |
141 |
141 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
320 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
86 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
140 |
$2K |
| D0602 |
|
29 |
29 |
$290.00 |