| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,935 |
228 |
$269K |
| D1120 |
Prophylaxis - child |
3,651 |
3,267 |
$190K |
| D1351 |
Sealant - per tooth |
2,782 |
575 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
2,861 |
2,526 |
$107K |
| D1206 |
Topical application of fluoride varnish |
4,219 |
3,742 |
$97K |
| D0272 |
Bitewings - two radiographic images |
1,885 |
1,658 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
435 |
125 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
806 |
711 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
360 |
164 |
$41K |
| D0240 |
|
1,556 |
709 |
$39K |
| D0330 |
Panoramic radiographic image |
327 |
306 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,267 |
394 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
862 |
662 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
125 |
42 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
142 |
111 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
99 |
93 |
$5K |
| D0274 |
Bitewings - four radiographic images |
86 |
82 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
68 |
$4K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |