| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,068 |
340 |
$108K |
| D1120 |
Prophylaxis - child |
3,302 |
3,200 |
$64K |
| D1354 |
|
3,984 |
1,016 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,845 |
2,776 |
$47K |
| D1206 |
Topical application of fluoride varnish |
3,207 |
3,136 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
757 |
350 |
$43K |
| D0330 |
Panoramic radiographic image |
670 |
658 |
$30K |
| D1351 |
Sealant - per tooth |
1,194 |
478 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
245 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
764 |
749 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
336 |
219 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,803 |
1,761 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,120 |
1,062 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,540 |
942 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
193 |
73 |
$12K |
| D0240 |
|
669 |
346 |
$8K |
| D0274 |
Bitewings - four radiographic images |
363 |
358 |
$7K |
| D1110 |
Prophylaxis - adult |
229 |
225 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,512 |
1,354 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
129 |
90 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
415 |
380 |
$6K |
| D2140 |
|
130 |
81 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
159 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
322 |
76 |
$589.24 |
| D1330 |
|
908 |
895 |
$0.00 |
| D0603 |
|
360 |
358 |
$0.00 |