| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,583 |
471 |
$290K |
| D1120 |
Prophylaxis - child |
2,363 |
2,243 |
$107K |
| D1206 |
Topical application of fluoride varnish |
2,261 |
2,145 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,834 |
1,738 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
305 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
398 |
191 |
$49K |
| D1351 |
Sealant - per tooth |
788 |
301 |
$33K |
| D0274 |
Bitewings - four radiographic images |
614 |
584 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
509 |
461 |
$28K |
| D0272 |
Bitewings - two radiographic images |
742 |
720 |
$25K |
| D0330 |
Panoramic radiographic image |
251 |
234 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
299 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
626 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
139 |
$8K |
| D9420 |
|
29 |
26 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
44 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
57 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$312.00 |
| D9995 |
|
13 |
13 |
$234.00 |