| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,655 |
818 |
$500K |
| D1120 |
Prophylaxis - child |
4,153 |
4,153 |
$174K |
| D1206 |
Topical application of fluoride varnish |
4,322 |
4,320 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
3,432 |
3,431 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,105 |
406 |
$99K |
| D9420 |
|
495 |
495 |
$70K |
| D0272 |
Bitewings - two radiographic images |
2,016 |
2,014 |
$47K |
| D1351 |
Sealant - per tooth |
1,229 |
511 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
217 |
$34K |
| D0240 |
|
1,574 |
951 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
153 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,146 |
1,129 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
343 |
$16K |
| D1354 |
|
468 |
277 |
$13K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
143 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
623 |
360 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
91 |
90 |
$4K |
| D1510 |
|
16 |
12 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$3K |
| D2330 |
|
16 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
946 |
888 |
$0.00 |