| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,756 |
481 |
$211K |
| D1120 |
Prophylaxis - child |
3,892 |
3,752 |
$117K |
| D1206 |
Topical application of fluoride varnish |
4,062 |
3,921 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
4,140 |
3,962 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,829 |
2,732 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,820 |
3,740 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
198 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,139 |
1,082 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,816 |
1,731 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,146 |
972 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
289 |
138 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
207 |
103 |
$19K |
| D1351 |
Sealant - per tooth |
670 |
227 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
120 |
$11K |
| D9310 |
|
177 |
174 |
$8K |
| D1110 |
Prophylaxis - adult |
137 |
132 |
$6K |
| D0603 |
|
418 |
400 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
81 |
$2K |
| D0601 |
|
200 |
199 |
$2K |
| D0602 |
|
158 |
149 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$975.36 |