| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,889 |
349 |
$191K |
| D1120 |
Prophylaxis - child |
3,530 |
3,506 |
$69K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
849 |
300 |
$54K |
| D1351 |
Sealant - per tooth |
2,693 |
676 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,726 |
2,707 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,009 |
3,002 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,588 |
1,577 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
647 |
328 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
208 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
277 |
101 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,175 |
1,160 |
$17K |
| D1110 |
Prophylaxis - adult |
545 |
536 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,774 |
1,758 |
$17K |
| D0274 |
Bitewings - four radiographic images |
430 |
426 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
19 |
$4K |
| D0240 |
|
310 |
160 |
$4K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
117 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
503 |
172 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
262 |
$1K |
| D1354 |
|
58 |
15 |
$870.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
27 |
$0.00 |