| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
942 |
286 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
788 |
370 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,006 |
348 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,177 |
1,112 |
$51K |
| D1120 |
Prophylaxis - child |
1,476 |
1,420 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
838 |
677 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
440 |
255 |
$35K |
| D1351 |
Sealant - per tooth |
1,025 |
333 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,577 |
1,502 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
125 |
$24K |
| D0330 |
Panoramic radiographic image |
354 |
338 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,573 |
732 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,033 |
946 |
$15K |
| D0240 |
|
780 |
398 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
450 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
146 |
87 |
$12K |
| D0272 |
Bitewings - two radiographic images |
658 |
630 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
310 |
289 |
$12K |
| D9420 |
|
53 |
47 |
$6K |
| D1354 |
|
549 |
121 |
$3K |
| D1110 |
Prophylaxis - adult |
82 |
81 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
22 |
$836.22 |
| D0274 |
Bitewings - four radiographic images |
29 |
26 |
$738.10 |
| D1310 |
|
1,032 |
1,014 |
$0.00 |
| D1330 |
|
1,025 |
1,011 |
$0.00 |