| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,221 |
825 |
$403K |
| D1120 |
Prophylaxis - child |
10,931 |
10,931 |
$381K |
| D0120 |
Periodic oral evaluation - established patient |
11,747 |
11,747 |
$274K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,630 |
797 |
$202K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,131 |
1,110 |
$194K |
| D1206 |
Topical application of fluoride varnish |
11,557 |
11,557 |
$190K |
| D1110 |
Prophylaxis - adult |
3,576 |
3,576 |
$179K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,989 |
618 |
$165K |
| D0272 |
Bitewings - two radiographic images |
5,941 |
5,941 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,056 |
3,027 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,926 |
1,926 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
782 |
467 |
$78K |
| D0330 |
Panoramic radiographic image |
1,495 |
1,495 |
$72K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,314 |
1,314 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,579 |
2,315 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
3,695 |
3,661 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
956 |
947 |
$37K |
| D9420 |
|
414 |
414 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,225 |
2,225 |
$36K |
| D0240 |
|
2,003 |
1,239 |
$35K |
| D9248 |
|
431 |
430 |
$28K |
| D0274 |
Bitewings - four radiographic images |
936 |
936 |
$26K |
| D2332 |
|
20 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
13 |
$1K |