| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,638 |
332 |
$158K |
| D1120 |
Prophylaxis - child |
4,869 |
4,711 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,080 |
4,917 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
4,163 |
3,999 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
913 |
431 |
$50K |
| D1351 |
Sealant - per tooth |
2,436 |
696 |
$49K |
| D0272 |
Bitewings - two radiographic images |
3,371 |
3,232 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
420 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,102 |
1,074 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,123 |
1,000 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
359 |
119 |
$20K |
| D0240 |
|
1,678 |
925 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
391 |
255 |
$18K |
| D0330 |
Panoramic radiographic image |
408 |
367 |
$17K |
| D0274 |
Bitewings - four radiographic images |
756 |
725 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
511 |
482 |
$11K |
| D1110 |
Prophylaxis - adult |
229 |
215 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
508 |
471 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
92 |
$740.00 |