| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,342 |
253 |
$212K |
| D9420 |
|
553 |
526 |
$104K |
| D1120 |
Prophylaxis - child |
3,238 |
3,149 |
$76K |
| D1351 |
Sealant - per tooth |
3,938 |
1,072 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
762 |
212 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,953 |
2,878 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
502 |
490 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,044 |
1,006 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
523 |
500 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,113 |
1,088 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
202 |
78 |
$16K |
| D0191 |
|
1,495 |
1,448 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,199 |
1,176 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
519 |
491 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
26 |
$4K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$525.20 |
| D0170 |
|
29 |
22 |
$445.50 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$438.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
25 |
$266.27 |