| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,646 |
416 |
$187K |
| D1120 |
Prophylaxis - child |
1,495 |
1,401 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,262 |
413 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
907 |
506 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,745 |
1,638 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
668 |
419 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,313 |
1,233 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
532 |
461 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,289 |
1,195 |
$18K |
| D0330 |
Panoramic radiographic image |
423 |
394 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,444 |
421 |
$11K |
| D1351 |
Sealant - per tooth |
412 |
151 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
652 |
$7K |
| D9420 |
|
95 |
95 |
$6K |
| D1206 |
Topical application of fluoride varnish |
310 |
307 |
$5K |
| D2331 |
|
61 |
45 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
128 |
$4K |
| D2330 |
|
75 |
43 |
$4K |
| D9248 |
|
30 |
30 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
40 |
38 |
$1K |
| D1354 |
|
46 |
22 |
$752.00 |
| D1110 |
Prophylaxis - adult |
15 |
14 |
$625.30 |
| D0274 |
Bitewings - four radiographic images |
14 |
13 |
$371.10 |
| D0603 |
|
23 |
22 |
$0.00 |