| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
476 |
122 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
545 |
207 |
$50K |
| D1351 |
Sealant - per tooth |
1,948 |
352 |
$50K |
| D0145 |
Oral evaluation for a patient under three years of age |
344 |
342 |
$48K |
| D1120 |
Prophylaxis - child |
1,161 |
1,147 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,086 |
1,070 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,359 |
1,341 |
$19K |
| D0272 |
Bitewings - two radiographic images |
772 |
760 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,447 |
1,380 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
434 |
430 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
191 |
53 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,285 |
1,166 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
373 |
354 |
$10K |
| D1110 |
Prophylaxis - adult |
148 |
147 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
98 |
$7K |
| D0274 |
Bitewings - four radiographic images |
108 |
107 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
128 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
17 |
$2K |
| D9248 |
|
13 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
14 |
$896.84 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$550.68 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$317.38 |
| D1999 |
|
372 |
354 |
$0.00 |
| D0603 |
|
2,236 |
2,208 |
$0.00 |