| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
687 |
316 |
$70K |
| D7140 |
Extraction, erupted tooth or exposed root |
608 |
255 |
$35K |
| D1120 |
Prophylaxis - child |
1,737 |
1,692 |
$33K |
| D0240 |
|
3,532 |
1,174 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,783 |
1,734 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
805 |
766 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
251 |
$20K |
| D0330 |
Panoramic radiographic image |
372 |
353 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
950 |
929 |
$15K |
| D1351 |
Sealant - per tooth |
585 |
222 |
$12K |
| D0272 |
Bitewings - two radiographic images |
958 |
940 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
125 |
$9K |
| D1510 |
|
44 |
29 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,476 |
397 |
$5K |
| D1321 |
|
276 |
271 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
736 |
568 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$641.00 |
| D1320 |
|
144 |
120 |
$519.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$316.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
625 |
587 |
$0.00 |
| D1999 |
|
378 |
335 |
$0.00 |