| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,009 |
835 |
$280K |
| D0240 |
|
6,312 |
2,924 |
$153K |
| D9248 |
|
1,411 |
1,263 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
3,509 |
3,116 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,303 |
591 |
$92K |
| D0272 |
Bitewings - two radiographic images |
3,553 |
3,151 |
$87K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
957 |
437 |
$82K |
| D1120 |
Prophylaxis - child |
2,121 |
1,868 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,603 |
3,208 |
$71K |
| D1110 |
Prophylaxis - adult |
1,470 |
1,328 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,396 |
2,109 |
$63K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
439 |
208 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
207 |
$25K |
| D0602 |
|
2,592 |
2,294 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
602 |
549 |
$11K |
| D2140 |
|
83 |
39 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
39 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
249 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
69 |
$2K |
| D1351 |
Sealant - per tooth |
78 |
38 |
$2K |
| D0601 |
|
91 |
89 |
$455.00 |