| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,992 |
1,345 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,550 |
2,060 |
$8K |
| D1120 |
Prophylaxis - child |
9,715 |
9,538 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,588 |
893 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,396 |
11,184 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,838 |
913 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,467 |
5,387 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,236 |
3,147 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
8,222 |
8,104 |
$2K |
| D9248 |
|
1,805 |
1,698 |
$2K |
| D1351 |
Sealant - per tooth |
2,895 |
954 |
$2K |
| D0330 |
Panoramic radiographic image |
1,995 |
1,958 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
497 |
218 |
$1K |
| D1110 |
Prophylaxis - adult |
1,648 |
1,615 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
6,943 |
6,703 |
$1K |
| D0274 |
Bitewings - four radiographic images |
2,651 |
2,594 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
1,362 |
1,245 |
$856.36 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,013 |
1,915 |
$854.29 |
| D0272 |
Bitewings - two radiographic images |
3,327 |
3,254 |
$714.25 |
| D1354 |
|
2,301 |
455 |
$666.96 |
| D0210 |
Intraoral - complete series of radiographic images |
417 |
354 |
$214.00 |
| D0601 |
|
151 |
151 |
$0.00 |
| D0602 |
|
22 |
22 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
25 |
$0.00 |
| D1999 |
|
2,396 |
2,245 |
$0.00 |