| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
725 |
319 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,168 |
1,151 |
$51K |
| D9248 |
|
344 |
327 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
601 |
293 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
445 |
443 |
$27K |
| D1120 |
Prophylaxis - child |
1,129 |
1,114 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
425 |
406 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
762 |
320 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,563 |
1,542 |
$15K |
| D1351 |
Sealant - per tooth |
778 |
281 |
$14K |
| D0330 |
Panoramic radiographic image |
335 |
326 |
$13K |
| D1110 |
Prophylaxis - adult |
346 |
344 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
38 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
104 |
53 |
$5K |
| D1330 |
|
1,558 |
1,537 |
$3K |
| D3120 |
|
289 |
198 |
$3K |
| D9920 |
|
281 |
271 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
29 |
$2K |
| D0240 |
|
600 |
450 |
$1K |
| D1999 |
|
24 |
24 |
$960.00 |
| D0272 |
Bitewings - two radiographic images |
1,134 |
1,124 |
$680.22 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
226 |
$231.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$212.56 |
| D2330 |
|
17 |
12 |
$170.00 |
| D0274 |
Bitewings - four radiographic images |
341 |
338 |
$83.00 |
| D0603 |
|
15 |
15 |
$5.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
27 |
$0.00 |