| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,049 |
493 |
$118K |
| D1120 |
Prophylaxis - child |
4,765 |
4,530 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,857 |
3,672 |
$49K |
| D1206 |
Topical application of fluoride varnish |
5,225 |
4,869 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,937 |
1,841 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
763 |
717 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
603 |
301 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,584 |
1,315 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,497 |
1,405 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
359 |
179 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,062 |
853 |
$6K |
| D1351 |
Sealant - per tooth |
750 |
213 |
$6K |
| D9248 |
|
193 |
164 |
$4K |
| D0330 |
Panoramic radiographic image |
201 |
199 |
$2K |
| D1354 |
|
190 |
49 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
46 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
12 |
$585.60 |
| D0274 |
Bitewings - four radiographic images |
53 |
50 |
$444.32 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$220.15 |
| D1999 |
|
42 |
38 |
$0.00 |
| D0603 |
|
569 |
536 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |
| D0601 |
|
69 |
64 |
$0.00 |