| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,026 |
1,188 |
$483K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,526 |
1,036 |
$179K |
| D0140 |
Limited oral evaluation - problem focused |
2,947 |
2,797 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
828 |
477 |
$50K |
| D0240 |
|
3,841 |
1,606 |
$47K |
| D1351 |
Sealant - per tooth |
1,762 |
593 |
$47K |
| D1120 |
Prophylaxis - child |
1,714 |
1,617 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,933 |
1,831 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,086 |
1,964 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
756 |
697 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
357 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
175 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
740 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
156 |
81 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
614 |
568 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
38 |
$350.00 |