| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,060 |
483 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
770 |
347 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,588 |
1,503 |
$41K |
| D1120 |
Prophylaxis - child |
2,029 |
1,932 |
$41K |
| D0240 |
|
3,065 |
1,401 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,857 |
1,756 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
493 |
301 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
267 |
$23K |
| D0330 |
Panoramic radiographic image |
364 |
356 |
$17K |
| D1351 |
Sealant - per tooth |
973 |
287 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
762 |
$14K |
| D0272 |
Bitewings - two radiographic images |
992 |
934 |
$10K |
| D1320 |
|
853 |
776 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,637 |
680 |
$9K |
| D1510 |
|
59 |
42 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
479 |
427 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
322 |
322 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,006 |
901 |
$5K |
| D2140 |
|
46 |
26 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$614.20 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$510.50 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$240.62 |
| D1999 |
|
501 |
449 |
$0.00 |