| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
607 |
236 |
$74K |
| D1351 |
Sealant - per tooth |
1,420 |
321 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
340 |
177 |
$28K |
| D1120 |
Prophylaxis - child |
730 |
728 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
439 |
434 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
914 |
911 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
300 |
189 |
$22K |
| D9248 |
|
92 |
92 |
$21K |
| D1206 |
Topical application of fluoride varnish |
868 |
867 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
281 |
131 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
218 |
155 |
$14K |
| D0272 |
Bitewings - two radiographic images |
572 |
571 |
$12K |
| D1110 |
Prophylaxis - adult |
188 |
187 |
$9K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$5K |
| D0603 |
|
455 |
452 |
$4K |
| D1330 |
|
685 |
682 |
$4K |
| D0240 |
|
155 |
114 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
92 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
179 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$676.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
50 |
$561.58 |
| D0602 |
|
25 |
25 |
$250.00 |