| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,705 |
587 |
$303K |
| D1120 |
Prophylaxis - child |
11,578 |
10,886 |
$235K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,611 |
11,879 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
10,056 |
9,484 |
$179K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,733 |
709 |
$106K |
| D1351 |
Sealant - per tooth |
3,877 |
1,022 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,069 |
2,884 |
$79K |
| D0330 |
Panoramic radiographic image |
1,584 |
1,535 |
$72K |
| D0272 |
Bitewings - two radiographic images |
5,303 |
4,996 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
833 |
445 |
$49K |
| D1110 |
Prophylaxis - adult |
1,396 |
1,326 |
$46K |
| D0240 |
|
3,051 |
1,184 |
$29K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
371 |
155 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
287 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
958 |
910 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
160 |
146 |
$4K |
| D0274 |
Bitewings - four radiographic images |
248 |
182 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
106 |
$567.55 |