| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
975 |
306 |
$105K |
| D1120 |
Prophylaxis - child |
1,765 |
1,670 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
588 |
336 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,414 |
1,331 |
$35K |
| D9920 |
|
417 |
370 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,129 |
1,066 |
$20K |
| D1110 |
Prophylaxis - adult |
465 |
439 |
$20K |
| D0272 |
Bitewings - two radiographic images |
934 |
884 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
257 |
136 |
$16K |
| D1206 |
Topical application of fluoride varnish |
696 |
657 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
331 |
$15K |
| D1351 |
Sealant - per tooth |
553 |
184 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
128 |
54 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
302 |
269 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
830 |
768 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
165 |
158 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
331 |
312 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
52 |
$7K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
69 |
$840.00 |