| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
512 |
163 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,610 |
1,391 |
$30K |
| D1120 |
Prophylaxis - child |
937 |
917 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
177 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
434 |
366 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
223 |
114 |
$15K |
| D1351 |
Sealant - per tooth |
350 |
122 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
544 |
538 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
561 |
554 |
$9K |
| D1330 |
|
1,042 |
1,020 |
$9K |
| D1310 |
|
1,043 |
1,021 |
$8K |
| D2933 |
|
30 |
14 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
96 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
95 |
43 |
$7K |
| D0240 |
|
512 |
300 |
$7K |
| D0272 |
Bitewings - two radiographic images |
452 |
444 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
521 |
459 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
346 |
210 |
$3K |
| D0603 |
|
470 |
468 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
59 |
$2K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$238.83 |
| D9420 |
|
15 |
15 |
$0.00 |