| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
770 |
235 |
$157K |
| D1120 |
Prophylaxis - child |
1,558 |
1,558 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
540 |
238 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,612 |
1,611 |
$47K |
| D1351 |
Sealant - per tooth |
1,399 |
345 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
677 |
676 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
132 |
$28K |
| D0240 |
|
1,175 |
608 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
696 |
$24K |
| D9310 |
|
253 |
252 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,129 |
403 |
$16K |
| D0272 |
Bitewings - two radiographic images |
587 |
587 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
624 |
617 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
73 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
138 |
138 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
42 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$779.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
487 |
444 |
$0.00 |