| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
534 |
146 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
551 |
200 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
124 |
$21K |
| D2934 |
|
149 |
40 |
$21K |
| D1120 |
Prophylaxis - child |
623 |
604 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
704 |
688 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
92 |
89 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
507 |
$11K |
| D1206 |
Topical application of fluoride varnish |
802 |
783 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
83 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
330 |
319 |
$8K |
| D1110 |
Prophylaxis - adult |
150 |
149 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
593 |
580 |
$6K |
| D0272 |
Bitewings - two radiographic images |
263 |
259 |
$5K |
| D9420 |
|
109 |
107 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
18 |
$4K |
| D0274 |
Bitewings - four radiographic images |
81 |
80 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
59 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
38 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
15 |
$768.39 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$225.36 |
| D0602 |
|
619 |
609 |
$0.00 |
| D0603 |
|
297 |
297 |
$0.00 |