| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,693 |
804 |
$270K |
| D1120 |
Prophylaxis - child |
8,662 |
8,592 |
$247K |
| D1206 |
Topical application of fluoride varnish |
10,400 |
10,300 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
8,895 |
8,807 |
$220K |
| D1351 |
Sealant - per tooth |
4,322 |
1,242 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,522 |
1,146 |
$127K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,416 |
851 |
$120K |
| D1110 |
Prophylaxis - adult |
1,829 |
1,794 |
$86K |
| D0330 |
Panoramic radiographic image |
1,058 |
1,048 |
$77K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
748 |
565 |
$62K |
| D0272 |
Bitewings - two radiographic images |
3,785 |
3,743 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,351 |
1,337 |
$51K |
| D0274 |
Bitewings - four radiographic images |
557 |
555 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
178 |
130 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
278 |
269 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,796 |
1,767 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
195 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,055 |
960 |
$8K |
| D0270 |
|
39 |
39 |
$195.00 |