| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,030 |
627 |
$171K |
| D1120 |
Prophylaxis - child |
5,800 |
5,747 |
$155K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,059 |
2,044 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,944 |
1,083 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
5,963 |
5,910 |
$70K |
| D0330 |
Panoramic radiographic image |
981 |
969 |
$62K |
| D1351 |
Sealant - per tooth |
3,473 |
730 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
958 |
665 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
670 |
663 |
$28K |
| D0240 |
|
457 |
453 |
$9K |
| D1110 |
Prophylaxis - adult |
163 |
162 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
365 |
222 |
$5K |
| D0601 |
|
5,837 |
5,780 |
$5K |
| D1330 |
|
6,603 |
6,546 |
$3K |
| D9920 |
|
42 |
39 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,012 |
1,902 |
$1K |
| D1999 |
|
23 |
22 |
$1K |
| D7111 |
|
21 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
77 |
$650.91 |
| D0274 |
Bitewings - four radiographic images |
154 |
153 |
$74.96 |
| D0272 |
Bitewings - two radiographic images |
2,552 |
2,529 |
$44.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
6,605 |
6,547 |
$41.98 |
| D0220 |
Intraoral - periapical first radiographic image |
2,259 |
2,240 |
$16.37 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
112 |
81 |
$0.00 |
| D9911 |
|
231 |
162 |
$0.00 |