| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,939 |
746 |
$592K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,884 |
1,013 |
$452K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
523 |
244 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,502 |
1,326 |
$89K |
| D0240 |
|
2,629 |
1,435 |
$80K |
| D0272 |
Bitewings - two radiographic images |
2,124 |
1,827 |
$60K |
| D1120 |
Prophylaxis - child |
1,917 |
1,603 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
392 |
166 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
609 |
469 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,267 |
1,876 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,494 |
1,259 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,430 |
660 |
$20K |
| D0330 |
Panoramic radiographic image |
151 |
131 |
$13K |
| D1351 |
Sealant - per tooth |
480 |
148 |
$11K |
| D2933 |
|
42 |
14 |
$9K |
| D9248 |
|
99 |
72 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
78 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
633 |
502 |
$2K |
| D9310 |
|
12 |
12 |
$897.60 |
| D1110 |
Prophylaxis - adult |
19 |
12 |
$83.30 |
| D1206 |
Topical application of fluoride varnish |
70 |
69 |
$0.00 |
| D1330 |
|
356 |
322 |
$0.00 |
| D1310 |
|
345 |
310 |
$0.00 |
| D0603 |
|
149 |
129 |
$0.00 |
| D0601 |
|
37 |
36 |
$0.00 |
| D0191 |
|
148 |
142 |
$0.00 |
| D1999 |
|
20 |
17 |
$0.00 |