| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
706 |
151 |
$8K |
| D1120 |
Prophylaxis - child |
2,793 |
2,773 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,078 |
4,055 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
615 |
303 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,078 |
1,069 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
2,361 |
2,355 |
$2K |
| D0330 |
Panoramic radiographic image |
531 |
523 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,527 |
1,506 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
650 |
601 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
144 |
61 |
$820.06 |
| D0230 |
Intraoral - periapical each additional radiographic image |
478 |
426 |
$717.16 |
| D1351 |
Sealant - per tooth |
332 |
104 |
$662.22 |
| D0240 |
|
334 |
290 |
$623.62 |
| D0220 |
Intraoral - periapical first radiographic image |
965 |
953 |
$599.29 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
29 |
$507.11 |
| D0274 |
Bitewings - four radiographic images |
337 |
335 |
$358.18 |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$168.48 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
58 |
29 |
$148.20 |
| D1110 |
Prophylaxis - adult |
115 |
115 |
$89.16 |