| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,307 |
674 |
$186K |
| D1120 |
Prophylaxis - child |
4,114 |
3,858 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
5,504 |
5,166 |
$119K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,356 |
689 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,398 |
833 |
$87K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
828 |
437 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,131 |
3,001 |
$65K |
| D1110 |
Prophylaxis - adult |
1,303 |
1,225 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,225 |
2,025 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,914 |
1,791 |
$43K |
| D1351 |
Sealant - per tooth |
1,474 |
402 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,541 |
1,387 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
630 |
422 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
893 |
837 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
812 |
774 |
$28K |
| D9248 |
|
1,014 |
874 |
$25K |
| D9920 |
|
491 |
409 |
$17K |
| D0274 |
Bitewings - four radiographic images |
522 |
496 |
$17K |
| D1510 |
|
15 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
220 |
$3K |