| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,276 |
325 |
$144K |
| D1351 |
Sealant - per tooth |
5,233 |
909 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,219 |
551 |
$95K |
| D1120 |
Prophylaxis - child |
4,575 |
3,609 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,039 |
1,917 |
$63K |
| D1206 |
Topical application of fluoride varnish |
2,859 |
2,681 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,134 |
1,058 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,172 |
1,707 |
$23K |
| D0330 |
Panoramic radiographic image |
710 |
643 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,890 |
1,157 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
312 |
151 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
138 |
$16K |
| D0274 |
Bitewings - four radiographic images |
692 |
650 |
$14K |
| D9248 |
|
250 |
247 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,037 |
987 |
$11K |
| D2934 |
|
51 |
15 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,343 |
776 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
207 |
189 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
528 |
469 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
21 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
22 |
22 |
$906.60 |
| D0603 |
|
2,187 |
1,530 |
$0.00 |
| D0601 |
|
26 |
26 |
$0.00 |