| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
686 |
356 |
$120K |
| D7140 |
Extraction, erupted tooth or exposed root |
841 |
367 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
638 |
385 |
$62K |
| D1120 |
Prophylaxis - child |
1,544 |
1,510 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
794 |
762 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,219 |
1,190 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,657 |
1,622 |
$30K |
| D1351 |
Sealant - per tooth |
992 |
342 |
$28K |
| D9420 |
|
94 |
90 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
934 |
920 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,038 |
1,017 |
$21K |
| D0240 |
|
740 |
559 |
$16K |
| D1354 |
|
1,410 |
453 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
127 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
99 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
160 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
359 |
$5K |