| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
597 |
220 |
$72K |
| D1120 |
Prophylaxis - child |
1,638 |
1,435 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
707 |
376 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,757 |
1,557 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
895 |
758 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
448 |
182 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
567 |
301 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
732 |
669 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
912 |
724 |
$21K |
| D1354 |
|
1,499 |
367 |
$19K |
| D0240 |
|
706 |
314 |
$15K |
| D0272 |
Bitewings - two radiographic images |
654 |
571 |
$15K |
| D1351 |
Sealant - per tooth |
470 |
179 |
$14K |
| D0330 |
Panoramic radiographic image |
218 |
215 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
599 |
443 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
703 |
648 |
$11K |
| D0603 |
|
1,036 |
893 |
$8K |
| D1355 |
|
1,092 |
175 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
96 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
42 |
12 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
51 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
47 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$1K |
| D3120 |
|
15 |
12 |
$0.00 |