| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,185 |
268 |
$106K |
| D1120 |
Prophylaxis - child |
1,088 |
993 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,269 |
1,155 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
310 |
150 |
$15K |
| D1351 |
Sealant - per tooth |
836 |
214 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
619 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
270 |
88 |
$12K |
| D0272 |
Bitewings - two radiographic images |
765 |
675 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,102 |
964 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,056 |
877 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
395 |
336 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
354 |
350 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
66 |
$5K |
| D0330 |
Panoramic radiographic image |
140 |
138 |
$5K |
| D9310 |
|
218 |
192 |
$5K |
| D1110 |
Prophylaxis - adult |
94 |
89 |
$3K |
| D9420 |
|
64 |
55 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
92 |
89 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
41 |
$994.09 |