| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
810 |
258 |
$4K |
| D1120 |
Prophylaxis - child |
3,220 |
3,212 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
971 |
579 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
286 |
140 |
$640.74 |
| D1206 |
Topical application of fluoride varnish |
3,744 |
3,734 |
$625.17 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
890 |
886 |
$505.24 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
108 |
53 |
$502.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,965 |
1,261 |
$496.61 |
| D0272 |
Bitewings - two radiographic images |
1,776 |
1,775 |
$319.08 |
| D0120 |
Periodic oral evaluation - established patient |
2,530 |
2,526 |
$304.96 |
| D0220 |
Intraoral - periapical first radiographic image |
1,616 |
1,591 |
$297.94 |
| D1351 |
Sealant - per tooth |
972 |
392 |
$291.45 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
597 |
562 |
$272.02 |
| D0145 |
Oral evaluation for a patient under three years of age |
306 |
304 |
$165.39 |
| D0330 |
Panoramic radiographic image |
720 |
717 |
$151.34 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
164 |
$57.15 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$28.58 |
| D1110 |
Prophylaxis - adult |
530 |
529 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
955 |
950 |
$0.00 |
| D1354 |
|
39 |
13 |
$0.00 |
| D0603 |
|
2,783 |
2,734 |
$0.00 |