| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,654 |
569 |
$180K |
| D1120 |
Prophylaxis - child |
2,681 |
2,648 |
$78K |
| D1351 |
Sealant - per tooth |
3,037 |
588 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,707 |
1,688 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,814 |
2,777 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
717 |
390 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
381 |
224 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
409 |
257 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
976 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,156 |
1,138 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
148 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
833 |
779 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
511 |
509 |
$15K |
| D0330 |
Panoramic radiographic image |
270 |
267 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
936 |
865 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,037 |
474 |
$8K |
| D0240 |
|
482 |
332 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
159 |
$4K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$3K |
| D9420 |
|
69 |
67 |
$2K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
20 |
$900.64 |
| D1354 |
|
123 |
40 |
$542.35 |
| D9219 |
|
28 |
27 |
$0.00 |