| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,399 |
252 |
$200K |
| D0120 |
Periodic oral evaluation - established patient |
7,336 |
6,959 |
$166K |
| D1110 |
Prophylaxis - adult |
3,201 |
3,025 |
$109K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,928 |
7,535 |
$107K |
| D8670 |
Periodic orthodontic treatment visit |
1,139 |
1,094 |
$102K |
| D1120 |
Prophylaxis - child |
3,871 |
3,665 |
$84K |
| D9420 |
|
404 |
394 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
837 |
769 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
455 |
131 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
429 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
209 |
90 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,158 |
1,110 |
$15K |
| D0274 |
Bitewings - four radiographic images |
315 |
283 |
$7K |
| D0240 |
|
286 |
160 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
16 |
$1K |
| D1351 |
Sealant - per tooth |
67 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$384.30 |
| D1354 |
|
21 |
12 |
$110.00 |