| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,625 |
496 |
$166K |
| D1120 |
Prophylaxis - child |
3,286 |
3,280 |
$100K |
| D1206 |
Topical application of fluoride varnish |
3,821 |
3,800 |
$68K |
| D1351 |
Sealant - per tooth |
2,284 |
591 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,652 |
2,652 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
715 |
390 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
761 |
646 |
$34K |
| D1310 |
|
2,374 |
2,369 |
$27K |
| D1330 |
|
2,327 |
2,323 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,573 |
1,570 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,194 |
1,190 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
256 |
$18K |
| D1110 |
Prophylaxis - adult |
414 |
414 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
130 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,201 |
1,192 |
$10K |
| D1354 |
|
281 |
220 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
860 |
832 |
$8K |
| D0330 |
Panoramic radiographic image |
160 |
160 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
63 |
42 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
97 |
96 |
$2K |
| D2330 |
|
22 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$447.84 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$425.60 |