| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,736 |
697 |
$344K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,636 |
1,116 |
$174K |
| D1120 |
Prophylaxis - child |
6,397 |
6,334 |
$144K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,749 |
879 |
$123K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,373 |
474 |
$110K |
| D1206 |
Topical application of fluoride varnish |
6,233 |
6,167 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
4,244 |
4,220 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,303 |
2,260 |
$68K |
| D1351 |
Sealant - per tooth |
2,241 |
655 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
629 |
368 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,312 |
1,292 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,915 |
2,865 |
$34K |
| D0330 |
Panoramic radiographic image |
358 |
358 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,641 |
1,617 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
322 |
308 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,261 |
1,034 |
$8K |
| D0274 |
Bitewings - four radiographic images |
245 |
243 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
36 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
277 |
$4K |
| D1110 |
Prophylaxis - adult |
68 |
68 |
$3K |
| D1510 |
|
20 |
12 |
$2K |
| D1354 |
|
46 |
18 |
$1K |
| D0240 |
|
41 |
29 |
$648.00 |
| D1999 |
|
40 |
38 |
$0.00 |