| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
929 |
240 |
$123K |
| D1120 |
Prophylaxis - child |
3,242 |
3,242 |
$105K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,152 |
4,152 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
3,824 |
3,824 |
$74K |
| D1110 |
Prophylaxis - adult |
982 |
982 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,904 |
1,904 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
544 |
290 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
269 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
462 |
307 |
$33K |
| D1351 |
Sealant - per tooth |
997 |
313 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
599 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
228 |
228 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
277 |
274 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
49 |
$8K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$8K |
| D2933 |
|
35 |
13 |
$6K |
| D9248 |
|
41 |
40 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
195 |
195 |
$2K |
| D9310 |
|
13 |
13 |
$1K |