| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,175 |
202 |
$85K |
| D1120 |
Prophylaxis - child |
6,454 |
4,026 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
5,975 |
3,713 |
$64K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,052 |
185 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,676 |
2,947 |
$35K |
| D0330 |
Panoramic radiographic image |
1,204 |
802 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
689 |
257 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
605 |
207 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
374 |
129 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,382 |
852 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,681 |
1,019 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
739 |
448 |
$11K |
| D1351 |
Sealant - per tooth |
539 |
61 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,075 |
642 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
48 |
$1K |
| D9630 |
|
50 |
32 |
$0.00 |
| D1330 |
|
229 |
165 |
$0.00 |