| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
949 |
294 |
$3K |
| D1120 |
Prophylaxis - child |
3,994 |
3,841 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,488 |
675 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
3,432 |
3,303 |
$1K |
| D1206 |
Topical application of fluoride varnish |
3,957 |
3,801 |
$1K |
| D0272 |
Bitewings - two radiographic images |
2,499 |
2,379 |
$852.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
836 |
792 |
$806.26 |
| D0220 |
Intraoral - periapical first radiographic image |
2,898 |
2,743 |
$710.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
631 |
335 |
$688.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,812 |
2,410 |
$538.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
981 |
853 |
$425.00 |
| D0274 |
Bitewings - four radiographic images |
503 |
474 |
$298.00 |
| D1110 |
Prophylaxis - adult |
331 |
312 |
$280.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
248 |
119 |
$280.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
216 |
105 |
$165.00 |
| D0140 |
Limited oral evaluation - problem focused |
426 |
397 |
$147.00 |
| D0330 |
Panoramic radiographic image |
443 |
413 |
$128.00 |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
280 |
$116.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
304 |
297 |
$91.00 |
| D0240 |
|
920 |
641 |
$90.00 |
| D1351 |
Sealant - per tooth |
404 |
122 |
$85.00 |
| D9248 |
|
41 |
38 |
$80.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
108 |
103 |
$0.00 |