| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,082 |
635 |
$331K |
| D1120 |
Prophylaxis - child |
4,052 |
3,791 |
$83K |
| D1206 |
Topical application of fluoride varnish |
4,097 |
3,832 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
3,169 |
2,945 |
$61K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
820 |
318 |
$54K |
| D2335 |
|
527 |
183 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
867 |
447 |
$46K |
| D0240 |
|
4,590 |
1,835 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
752 |
329 |
$43K |
| D0272 |
Bitewings - two radiographic images |
3,114 |
2,916 |
$33K |
| D1351 |
Sealant - per tooth |
1,478 |
491 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
932 |
917 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
978 |
932 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
762 |
732 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
130 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
847 |
784 |
$4K |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
250 |
116 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$409.56 |
| D9420 |
|
403 |
376 |
$153.36 |