| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,549 |
534 |
$172K |
| D1120 |
Prophylaxis - child |
4,677 |
4,655 |
$160K |
| D1206 |
Topical application of fluoride varnish |
4,931 |
4,910 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,275 |
621 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,256 |
3,247 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,624 |
2,256 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,045 |
473 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,218 |
2,193 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
3,230 |
3,152 |
$39K |
| D0330 |
Panoramic radiographic image |
854 |
847 |
$35K |
| D1351 |
Sealant - per tooth |
1,065 |
382 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
993 |
909 |
$28K |
| D0272 |
Bitewings - two radiographic images |
727 |
721 |
$12K |
| D0274 |
Bitewings - four radiographic images |
384 |
383 |
$10K |
| D9248 |
|
113 |
102 |
$9K |
| D1110 |
Prophylaxis - adult |
166 |
166 |
$6K |
| D2929 |
|
53 |
26 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
66 |
37 |
$5K |
| D1510 |
|
21 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
30 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
75 |
$2K |
| D2331 |
|
19 |
12 |
$1K |
| D1354 |
|
158 |
62 |
$1K |
| D9420 |
|
127 |
121 |
$75.00 |