| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,735 |
1,008 |
$467K |
| D1120 |
Prophylaxis - child |
9,450 |
9,377 |
$231K |
| D1206 |
Topical application of fluoride varnish |
11,356 |
11,223 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
8,747 |
8,693 |
$155K |
| D1351 |
Sealant - per tooth |
7,030 |
1,734 |
$143K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,683 |
2,643 |
$123K |
| D0272 |
Bitewings - two radiographic images |
5,704 |
5,665 |
$91K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,367 |
807 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
676 |
399 |
$58K |
| D9420 |
|
257 |
251 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,007 |
1,004 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,936 |
1,915 |
$48K |
| D1110 |
Prophylaxis - adult |
1,172 |
1,167 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
188 |
$28K |
| D0240 |
|
1,572 |
1,103 |
$27K |
| D1354 |
|
3,463 |
1,395 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
56 |
41 |
$5K |
| D2330 |
|
43 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
292 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$3K |