| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,590 |
538 |
$346K |
| D1120 |
Prophylaxis - child |
2,840 |
2,801 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,190 |
3,138 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,969 |
1,936 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
609 |
285 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
892 |
848 |
$50K |
| D9420 |
|
122 |
122 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,696 |
1,675 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,514 |
1,498 |
$33K |
| D0240 |
|
1,326 |
1,097 |
$32K |
| D1354 |
|
2,267 |
732 |
$22K |
| D1351 |
Sealant - per tooth |
741 |
257 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
124 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
107 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
43 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$774.60 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$699.76 |