| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,969 |
643 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,972 |
1,149 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
3,383 |
3,325 |
$69K |
| D1120 |
Prophylaxis - child |
3,075 |
3,017 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,140 |
701 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,241 |
3,189 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,303 |
2,261 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,642 |
1,535 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
682 |
372 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
819 |
802 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
447 |
202 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,330 |
1,525 |
$19K |
| D1110 |
Prophylaxis - adult |
703 |
695 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,048 |
2,006 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
668 |
643 |
$15K |
| D0330 |
Panoramic radiographic image |
511 |
510 |
$13K |
| D1206 |
Topical application of fluoride varnish |
889 |
876 |
$10K |
| D0274 |
Bitewings - four radiographic images |
584 |
579 |
$10K |
| D1351 |
Sealant - per tooth |
589 |
251 |
$9K |
| D9420 |
|
89 |
77 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
99 |
99 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$417.00 |