| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
490 |
93 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,502 |
1,045 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
561 |
102 |
$15K |
| D2934 |
|
55 |
15 |
$7K |
| D1120 |
Prophylaxis - child |
4,755 |
4,702 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
5,453 |
5,365 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,911 |
1,895 |
$1K |
| D0272 |
Bitewings - two radiographic images |
1,095 |
1,067 |
$1K |
| D1206 |
Topical application of fluoride varnish |
5,053 |
4,973 |
$961.87 |
| D0220 |
Intraoral - periapical first radiographic image |
2,613 |
2,497 |
$916.38 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
430 |
200 |
$697.20 |
| D1110 |
Prophylaxis - adult |
1,369 |
1,347 |
$484.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
254 |
$235.50 |
| D0274 |
Bitewings - four radiographic images |
690 |
680 |
$187.02 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
214 |
209 |
$33.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
902 |
875 |
$17.00 |
| D1354 |
|
4,446 |
894 |
$0.00 |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$0.00 |
| D9248 |
|
24 |
24 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
139 |
130 |
$0.00 |