| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,087 |
517 |
$106K |
| D1120 |
Prophylaxis - child |
2,746 |
2,739 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,334 |
840 |
$76K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,437 |
1,384 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,756 |
2,750 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,197 |
2,194 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
663 |
395 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,671 |
1,670 |
$27K |
| D1351 |
Sealant - per tooth |
983 |
362 |
$23K |
| D0330 |
Panoramic radiographic image |
490 |
490 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
852 |
852 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
231 |
$15K |
| D8670 |
Periodic orthodontic treatment visit |
146 |
146 |
$14K |
| D1330 |
|
1,896 |
1,896 |
$8K |
| D1110 |
Prophylaxis - adult |
212 |
212 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
90 |
61 |
$7K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$3K |
| D0601 |
|
367 |
367 |
$3K |
| D0603 |
|
343 |
343 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
75 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
257 |
$2K |
| D1354 |
|
115 |
81 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$675.00 |
| D1310 |
|
260 |
260 |
$620.00 |
| D0240 |
|
51 |
51 |
$588.00 |
| D0602 |
|
47 |
47 |
$430.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
14 |
$192.74 |
| D1999 |
|
199 |
195 |
$0.00 |