| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,420 |
373 |
$163K |
| D1120 |
Prophylaxis - child |
1,962 |
1,949 |
$113K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,180 |
356 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
844 |
385 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
710 |
256 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
455 |
220 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,135 |
1,130 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,163 |
2,150 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
865 |
$22K |
| D9420 |
|
318 |
313 |
$18K |
| D0272 |
Bitewings - two radiographic images |
860 |
852 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,016 |
995 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
893 |
582 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
172 |
161 |
$6K |
| D0330 |
Panoramic radiographic image |
114 |
110 |
$5K |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$4K |
| D1351 |
Sealant - per tooth |
126 |
40 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$909.14 |