| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
944 |
413 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
674 |
396 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
715 |
321 |
$75K |
| D1120 |
Prophylaxis - child |
1,517 |
1,452 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
831 |
780 |
$47K |
| D9310 |
|
467 |
467 |
$46K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
288 |
200 |
$39K |
| D1351 |
Sealant - per tooth |
1,187 |
324 |
$38K |
| D0240 |
|
1,504 |
728 |
$30K |
| D1206 |
Topical application of fluoride varnish |
931 |
930 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,669 |
595 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
516 |
504 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
797 |
764 |
$14K |
| D0330 |
Panoramic radiographic image |
212 |
212 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
97 |
$12K |
| D0272 |
Bitewings - two radiographic images |
479 |
447 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
150 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
466 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
175 |
175 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
491 |
449 |
$105.00 |