| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,392 |
565 |
$152K |
| D1120 |
Prophylaxis - child |
4,350 |
4,329 |
$146K |
| D0120 |
Periodic oral evaluation - established patient |
4,804 |
4,775 |
$117K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,782 |
4,755 |
$101K |
| D9248 |
|
692 |
653 |
$61K |
| D1351 |
Sealant - per tooth |
1,379 |
526 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
333 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
570 |
373 |
$35K |
| D0330 |
Panoramic radiographic image |
640 |
636 |
$30K |
| D1110 |
Prophylaxis - adult |
580 |
573 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
303 |
204 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,380 |
1,375 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,065 |
1,060 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
712 |
712 |
$21K |
| D1354 |
|
2,121 |
685 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
332 |
173 |
$20K |
| D0274 |
Bitewings - four radiographic images |
622 |
617 |
$17K |
| D1353 |
|
617 |
238 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,251 |
1,214 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
401 |
395 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,274 |
723 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
307 |
305 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
239 |
232 |
$5K |
| D2330 |
|
26 |
14 |
$1K |
| D2920 |
|
14 |
13 |
$356.22 |
| D9420 |
|
74 |
71 |
$0.00 |