| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
727 |
206 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
722 |
339 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,029 |
1,982 |
$54K |
| D1120 |
Prophylaxis - child |
1,626 |
1,592 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
325 |
323 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
438 |
236 |
$31K |
| D1206 |
Topical application of fluoride varnish |
2,200 |
2,150 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,839 |
1,319 |
$27K |
| D1110 |
Prophylaxis - adult |
560 |
549 |
$27K |
| D2934 |
|
184 |
53 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
612 |
596 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,535 |
1,487 |
$16K |
| D0272 |
Bitewings - two radiographic images |
723 |
702 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
117 |
$11K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
142 |
68 |
$11K |
| D0274 |
Bitewings - four radiographic images |
333 |
324 |
$10K |
| D0330 |
Panoramic radiographic image |
175 |
170 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
210 |
$7K |
| D9420 |
|
108 |
108 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
177 |
$3K |
| D1351 |
Sealant - per tooth |
95 |
27 |
$3K |
| D0602 |
|
1,856 |
1,836 |
$0.00 |
| D0603 |
|
802 |
793 |
$0.00 |