| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,107 |
383 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
3,501 |
3,481 |
$120K |
| D1120 |
Prophylaxis - child |
3,101 |
3,094 |
$104K |
| D1206 |
Topical application of fluoride varnish |
3,630 |
3,591 |
$89K |
| D1110 |
Prophylaxis - adult |
1,048 |
1,045 |
$52K |
| D0274 |
Bitewings - four radiographic images |
803 |
799 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,193 |
1,191 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
329 |
205 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,636 |
1,386 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
552 |
$26K |
| D1351 |
Sealant - per tooth |
1,196 |
351 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
865 |
858 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
804 |
510 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
142 |
$7K |
| D0330 |
Panoramic radiographic image |
85 |
85 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
38 |
$6K |
| D1352 |
|
106 |
44 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
12 |
$2K |
| D2140 |
|
16 |
12 |
$669.76 |
| D1999 |
|
263 |
254 |
$0.00 |
| D3120 |
|
208 |
94 |
$0.00 |