| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,931 |
795 |
$403K |
| D1120 |
Prophylaxis - child |
3,364 |
3,336 |
$128K |
| D7140 |
Extraction, erupted tooth or exposed root |
926 |
412 |
$82K |
| D2390 |
|
334 |
134 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
857 |
436 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,391 |
3,364 |
$62K |
| D9310 |
|
437 |
407 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,113 |
1,137 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,444 |
1,426 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,683 |
1,675 |
$45K |
| D1351 |
Sealant - per tooth |
1,346 |
414 |
$44K |
| D0240 |
|
1,858 |
992 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,576 |
1,481 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,666 |
1,643 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
810 |
727 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
422 |
422 |
$21K |
| D0603 |
|
3,173 |
3,112 |
$19K |
| D1510 |
|
101 |
70 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
138 |
88 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
358 |
341 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
451 |
446 |
$12K |
| D1354 |
|
2,076 |
750 |
$10K |
| D0330 |
Panoramic radiographic image |
630 |
598 |
$8K |
| D2933 |
|
43 |
12 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
56 |
$6K |
| D2330 |
|
74 |
32 |
$5K |
| D2929 |
|
40 |
12 |
$4K |
| D1999 |
|
1,675 |
1,435 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
26 |
$3K |
| D9920 |
|
38 |
37 |
$2K |
| D1320 |
|
119 |
114 |
$1K |
| D0602 |
|
132 |
132 |
$1K |
| D0170 |
|
26 |
26 |
$768.00 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$759.60 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$651.89 |
| D0601 |
|
41 |
41 |
$308.00 |
| D1330 |
|
3,442 |
3,419 |
$10.13 |
| D1310 |
|
3,428 |
3,404 |
$0.03 |