| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,618 |
311 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,514 |
1,136 |
$66K |
| D1120 |
Prophylaxis - child |
4,888 |
4,840 |
$50K |
| D1206 |
Topical application of fluoride varnish |
6,153 |
6,089 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,407 |
5,944 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
3,945 |
3,900 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
6,914 |
6,722 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,377 |
2,350 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
830 |
475 |
$18K |
| D1110 |
Prophylaxis - adult |
1,340 |
1,317 |
$17K |
| D0272 |
Bitewings - two radiographic images |
3,109 |
3,071 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
401 |
147 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
536 |
284 |
$15K |
| D0274 |
Bitewings - four radiographic images |
1,313 |
1,293 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
846 |
813 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
225 |
131 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,097 |
1,020 |
$8K |
| D0330 |
Panoramic radiographic image |
389 |
373 |
$2K |
| D1351 |
Sealant - per tooth |
325 |
125 |
$1K |
| D2332 |
|
24 |
12 |
$305.75 |
| D9430 |
|
12 |
12 |
$97.20 |
| D0270 |
|
18 |
18 |
$72.91 |
| D0603 |
|
1,334 |
1,298 |
$0.00 |
| D0602 |
|
556 |
531 |
$0.00 |
| D0601 |
|
380 |
353 |
$0.00 |