| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,761 |
636 |
$277K |
| D1120 |
Prophylaxis - child |
3,746 |
3,617 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
4,769 |
4,612 |
$103K |
| D1206 |
Topical application of fluoride varnish |
4,046 |
3,905 |
$74K |
| D1351 |
Sealant - per tooth |
3,070 |
635 |
$65K |
| D1110 |
Prophylaxis - adult |
1,318 |
1,285 |
$51K |
| D0272 |
Bitewings - two radiographic images |
2,064 |
1,988 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
1,152 |
1,092 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,168 |
1,133 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
331 |
164 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
210 |
102 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,061 |
996 |
$11K |
| D0274 |
Bitewings - four radiographic images |
346 |
337 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
42 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
283 |
$3K |
| D9420 |
|
41 |
41 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
30 |
$1K |
| D0240 |
|
41 |
38 |
$490.96 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$389.52 |
| D1999 |
|
202 |
198 |
$0.00 |