| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,819 |
661 |
$285K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,016 |
672 |
$89K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,202 |
665 |
$86K |
| D1120 |
Prophylaxis - child |
1,598 |
1,523 |
$62K |
| D1206 |
Topical application of fluoride varnish |
1,747 |
1,652 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,478 |
1,378 |
$32K |
| D1351 |
Sealant - per tooth |
925 |
274 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,073 |
1,043 |
$28K |
| D9410 |
|
34 |
34 |
$16K |
| D0272 |
Bitewings - two radiographic images |
638 |
615 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
134 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
127 |
61 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
674 |
$10K |
| D1110 |
Prophylaxis - adult |
141 |
117 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
195 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
147 |
$4K |
| D0274 |
Bitewings - four radiographic images |
87 |
63 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$2K |
| D2330 |
|
22 |
15 |
$2K |
| D1330 |
|
22 |
22 |
$0.00 |