| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
819 |
204 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
851 |
274 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
984 |
314 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
344 |
96 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
674 |
241 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
487 |
397 |
$18K |
| D1120 |
Prophylaxis - child |
2,075 |
1,796 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,035 |
871 |
$12K |
| D1351 |
Sealant - per tooth |
1,941 |
491 |
$11K |
| D0240 |
|
1,216 |
566 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
756 |
488 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,033 |
868 |
$9K |
| D1206 |
Topical application of fluoride varnish |
2,096 |
1,800 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,305 |
545 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
890 |
720 |
$5K |
| D1510 |
|
47 |
24 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
739 |
$2K |
| D0274 |
Bitewings - four radiographic images |
221 |
188 |
$1K |
| D1354 |
|
311 |
67 |
$1K |
| D0270 |
|
38 |
26 |
$135.00 |
| D1999 |
|
130 |
106 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
26 |
$0.00 |
| D1310 |
|
39 |
34 |
$0.00 |
| D1330 |
|
39 |
35 |
$0.00 |
| D0603 |
|
18 |
18 |
$0.00 |