| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,237 |
556 |
$214K |
| D1120 |
Prophylaxis - child |
6,319 |
6,131 |
$119K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,280 |
6,110 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
5,201 |
5,056 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
990 |
609 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
890 |
475 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,853 |
1,777 |
$47K |
| D1351 |
Sealant - per tooth |
2,316 |
612 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,867 |
2,766 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
436 |
185 |
$25K |
| D0240 |
|
2,599 |
956 |
$22K |
| D0330 |
Panoramic radiographic image |
373 |
363 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
909 |
831 |
$13K |
| D1110 |
Prophylaxis - adult |
151 |
144 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
47 |
$4K |
| D1206 |
Topical application of fluoride varnish |
92 |
85 |
$825.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$429.02 |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$420.00 |