| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
361 |
154 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
167 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
168 |
91 |
$22K |
| D2934 |
|
68 |
28 |
$16K |
| D1120 |
Prophylaxis - child |
2,878 |
2,859 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
158 |
96 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
77 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
675 |
239 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
3,221 |
3,181 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
955 |
931 |
$8K |
| D9248 |
|
105 |
103 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
380 |
$5K |
| D1351 |
Sealant - per tooth |
202 |
70 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
77 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$3K |
| D1206 |
Topical application of fluoride varnish |
2,429 |
2,414 |
$1K |
| D9310 |
|
13 |
13 |
$937.50 |
| D0272 |
Bitewings - two radiographic images |
1,174 |
1,161 |
$887.63 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
518 |
491 |
$66.96 |
| D0240 |
|
153 |
83 |
$0.00 |
| D1110 |
Prophylaxis - adult |
404 |
393 |
$0.00 |
| D0330 |
Panoramic radiographic image |
163 |
163 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
242 |
241 |
$0.00 |
| D1999 |
|
30 |
29 |
$0.00 |