| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
785 |
294 |
$95K |
| D1120 |
Prophylaxis - child |
2,257 |
2,257 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
641 |
381 |
$64K |
| D7140 |
Extraction, erupted tooth or exposed root |
585 |
274 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,941 |
1,941 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,371 |
2,371 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
310 |
154 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
732 |
676 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,076 |
1,076 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
161 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
442 |
$17K |
| D1351 |
Sealant - per tooth |
555 |
209 |
$16K |
| D0330 |
Panoramic radiographic image |
162 |
162 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
615 |
610 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
714 |
339 |
$6K |
| D0240 |
|
318 |
187 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
118 |
118 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
106 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$2K |
| D9420 |
|
12 |
12 |
$962.50 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$639.60 |