| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
800 |
266 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
719 |
365 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,087 |
2,050 |
$39K |
| D9248 |
|
324 |
322 |
$39K |
| D1120 |
Prophylaxis - child |
1,260 |
1,237 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,440 |
1,418 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
513 |
254 |
$32K |
| D1351 |
Sealant - per tooth |
1,105 |
219 |
$27K |
| D9920 |
|
301 |
300 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
316 |
214 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
205 |
100 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
298 |
288 |
$12K |
| D0272 |
Bitewings - two radiographic images |
754 |
739 |
$12K |
| D1110 |
Prophylaxis - adult |
276 |
270 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
205 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
111 |
111 |
$5K |
| D0330 |
Panoramic radiographic image |
91 |
90 |
$3K |
| D1330 |
|
570 |
569 |
$3K |
| D0603 |
|
285 |
284 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
253 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
152 |
$2K |
| D0602 |
|
167 |
167 |
$2K |
| D1310 |
|
37 |
37 |
$420.00 |
| D9420 |
|
17 |
15 |
$0.00 |
| D1999 |
|
20 |
20 |
$0.00 |