| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
996 |
328 |
$181K |
| D1120 |
Prophylaxis - child |
1,271 |
1,154 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
254 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,111 |
1,992 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
498 |
220 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
735 |
729 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,152 |
1,055 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
504 |
480 |
$28K |
| D0272 |
Bitewings - two radiographic images |
822 |
742 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
671 |
481 |
$13K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$13K |
| D1110 |
Prophylaxis - adult |
132 |
130 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
360 |
$7K |
| D1351 |
Sealant - per tooth |
125 |
44 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
448 |
199 |
$5K |
| D1510 |
|
23 |
14 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
14 |
$5K |
| D2330 |
|
43 |
12 |
$4K |
| D1354 |
|
135 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
47 |
$1K |
| D0603 |
|
25 |
25 |
$0.00 |