| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,184 |
306 |
$177K |
| D1120 |
Prophylaxis - child |
2,657 |
2,620 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,800 |
2,755 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,243 |
2,210 |
$64K |
| D1351 |
Sealant - per tooth |
2,032 |
481 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
519 |
293 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
630 |
233 |
$50K |
| D0272 |
Bitewings - two radiographic images |
1,143 |
1,135 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
179 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
491 |
$22K |
| D0240 |
|
739 |
630 |
$22K |
| D9420 |
|
122 |
118 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
650 |
589 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
198 |
194 |
$8K |
| D0274 |
Bitewings - four radiographic images |
203 |
199 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
325 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
391 |
169 |
$6K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$3K |
| D1353 |
|
146 |
56 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
13 |
$561.31 |