| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,743 |
512 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,521 |
969 |
$62K |
| D1120 |
Prophylaxis - child |
3,611 |
3,537 |
$34K |
| D0240 |
|
5,312 |
3,180 |
$27K |
| D1206 |
Topical application of fluoride varnish |
3,471 |
3,390 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,607 |
1,569 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
3,087 |
3,033 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
626 |
267 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
458 |
199 |
$15K |
| D0272 |
Bitewings - two radiographic images |
2,602 |
2,555 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
386 |
167 |
$13K |
| D2390 |
|
254 |
68 |
$11K |
| D2332 |
|
258 |
111 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,285 |
1,187 |
$9K |
| D1354 |
|
1,652 |
296 |
$8K |
| D1351 |
Sealant - per tooth |
1,143 |
357 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
120 |
$6K |
| D1110 |
Prophylaxis - adult |
367 |
354 |
$5K |
| D0274 |
Bitewings - four radiographic images |
533 |
529 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,001 |
956 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
431 |
$3K |
| D3230 |
|
93 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
115 |
$1K |
| D0603 |
|
2,166 |
2,069 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
728 |
713 |
$0.00 |