| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,059 |
270 |
$129K |
| D1120 |
Prophylaxis - child |
1,572 |
1,566 |
$95K |
| D7140 |
Extraction, erupted tooth or exposed root |
695 |
316 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,369 |
1,364 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,741 |
1,734 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
451 |
276 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
259 |
$24K |
| D0272 |
Bitewings - two radiographic images |
858 |
851 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
525 |
519 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
433 |
425 |
$16K |
| D1351 |
Sealant - per tooth |
638 |
252 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
205 |
104 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
964 |
947 |
$13K |
| D0330 |
Panoramic radiographic image |
176 |
175 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
818 |
776 |
$8K |
| D1110 |
Prophylaxis - adult |
118 |
116 |
$7K |
| D2335 |
|
45 |
24 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$2K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$530.82 |
| D1354 |
|
20 |
14 |
$268.80 |