| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
854 |
281 |
$86K |
| D1120 |
Prophylaxis - child |
3,169 |
3,113 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,037 |
360 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,478 |
3,421 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,463 |
2,442 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,177 |
1,153 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,420 |
2,392 |
$24K |
| D1351 |
Sealant - per tooth |
866 |
235 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,533 |
3,189 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
3,387 |
3,326 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
257 |
139 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
89 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
271 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
312 |
307 |
$6K |
| D0330 |
Panoramic radiographic image |
122 |
122 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
68 |
$6K |
| D1110 |
Prophylaxis - adult |
115 |
115 |
$4K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$2K |
| D1999 |
|
782 |
743 |
$0.00 |