| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
653 |
338 |
$64K |
| D1120 |
Prophylaxis - child |
1,814 |
1,793 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
851 |
467 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,148 |
987 |
$45K |
| D1206 |
Topical application of fluoride varnish |
2,048 |
2,021 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,533 |
1,519 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
560 |
350 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
367 |
226 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
672 |
661 |
$16K |
| D1351 |
Sealant - per tooth |
643 |
218 |
$15K |
| D0272 |
Bitewings - two radiographic images |
941 |
929 |
$15K |
| D1110 |
Prophylaxis - adult |
213 |
208 |
$8K |
| D1330 |
|
1,127 |
1,116 |
$6K |
| D0274 |
Bitewings - four radiographic images |
208 |
207 |
$6K |
| D1310 |
|
881 |
872 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
99 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
467 |
450 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
285 |
214 |
$3K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
15 |
$2K |
| D0240 |
|
122 |
82 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
91 |
$2K |
| D0601 |
|
281 |
277 |
$2K |
| D0603 |
|
249 |
249 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |
| D0273 |
|
13 |
13 |
$286.00 |
| D1354 |
|
37 |
12 |
$285.00 |
| D1999 |
|
501 |
404 |
$0.00 |