| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,160 |
603 |
$120K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
930 |
495 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
3,897 |
3,738 |
$58K |
| D1120 |
Prophylaxis - child |
2,639 |
2,528 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,654 |
3,499 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,153 |
716 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
778 |
419 |
$42K |
| D1110 |
Prophylaxis - adult |
1,118 |
1,077 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
988 |
931 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,541 |
1,384 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,329 |
1,269 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
275 |
$15K |
| D1351 |
Sealant - per tooth |
414 |
112 |
$11K |
| D0274 |
Bitewings - four radiographic images |
420 |
398 |
$9K |
| D9248 |
|
933 |
842 |
$7K |
| D0330 |
Panoramic radiographic image |
99 |
97 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
114 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
38 |
$463.75 |
| D9920 |
|
41 |
39 |
$46.75 |