| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
673 |
502 |
$142K |
| D1354 |
|
4,421 |
2,069 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,408 |
1,089 |
$112K |
| D1120 |
Prophylaxis - child |
2,773 |
2,668 |
$111K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,484 |
1,346 |
$99K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
707 |
531 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
856 |
716 |
$71K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
505 |
421 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,994 |
1,972 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,795 |
1,692 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,456 |
1,400 |
$40K |
| D1351 |
Sealant - per tooth |
601 |
392 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,538 |
2,749 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,758 |
1,702 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
432 |
380 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
3,087 |
2,992 |
$19K |
| D1510 |
|
60 |
59 |
$6K |
| D2940 |
|
306 |
186 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
216 |
209 |
$4K |
| D0272 |
Bitewings - two radiographic images |
413 |
399 |
$4K |
| D0274 |
Bitewings - four radiographic images |
231 |
208 |
$4K |
| D2330 |
|
14 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$147.45 |