| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,794 |
748 |
$303K |
| D1120 |
Prophylaxis - child |
7,535 |
7,444 |
$231K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,001 |
3,960 |
$137K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,424 |
7,334 |
$131K |
| D0272 |
Bitewings - two radiographic images |
4,798 |
4,711 |
$95K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,220 |
366 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,413 |
3,376 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
5,290 |
5,182 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
1,573 |
1,524 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,999 |
4,783 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,452 |
1,408 |
$38K |
| D9420 |
|
446 |
429 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
493 |
263 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
375 |
239 |
$26K |
| D2934 |
|
225 |
59 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
389 |
172 |
$24K |
| D1351 |
Sealant - per tooth |
618 |
199 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
172 |
$10K |
| D9248 |
|
39 |
39 |
$933.23 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$356.67 |
| D0240 |
|
17 |
14 |
$316.25 |
| D1999 |
|
80 |
67 |
$0.00 |