| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,430 |
577 |
$285K |
| D1120 |
Prophylaxis - child |
7,273 |
7,197 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
5,188 |
5,151 |
$143K |
| D1206 |
Topical application of fluoride varnish |
7,014 |
6,937 |
$121K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,009 |
3,078 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,909 |
1,873 |
$69K |
| D1351 |
Sealant - per tooth |
2,338 |
581 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
849 |
410 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
3,985 |
3,860 |
$49K |
| D0272 |
Bitewings - two radiographic images |
2,437 |
2,399 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
538 |
290 |
$42K |
| D0240 |
|
2,628 |
1,477 |
$42K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
401 |
180 |
$32K |
| D2929 |
|
136 |
38 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,328 |
1,280 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
696 |
678 |
$23K |
| D0603 |
|
5,400 |
5,318 |
$15K |
| D0330 |
Panoramic radiographic image |
236 |
234 |
$11K |
| D0602 |
|
598 |
588 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
42 |
$3K |
| D1515 |
|
19 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D0601 |
|
93 |
91 |
$539.00 |
| D1999 |
|
154 |
149 |
$364.00 |
| D1354 |
|
23 |
13 |
$276.00 |
| D9971 |
|
25 |
14 |
$0.00 |
| D1330 |
|
5,537 |
5,500 |
$0.00 |
| D0171 |
|
13 |
13 |
$0.00 |