| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,110 |
173 |
$99K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
507 |
131 |
$28K |
| D1120 |
Prophylaxis - child |
1,973 |
1,922 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,861 |
1,807 |
$18K |
| D1206 |
Topical application of fluoride varnish |
2,479 |
2,395 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
200 |
$15K |
| D2934 |
|
110 |
31 |
$13K |
| D0274 |
Bitewings - four radiographic images |
853 |
835 |
$11K |
| D1351 |
Sealant - per tooth |
669 |
212 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,792 |
1,161 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
488 |
481 |
$8K |
| D0272 |
Bitewings - two radiographic images |
978 |
958 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,347 |
1,296 |
$6K |
| D1110 |
Prophylaxis - adult |
287 |
282 |
$6K |
| D0330 |
Panoramic radiographic image |
218 |
216 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
84 |
$4K |
| D0240 |
|
504 |
463 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
269 |
246 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
51 |
$611.32 |
| D0350 |
|
80 |
80 |
$588.16 |
| D9248 |
|
12 |
12 |
$152.42 |
| D9222 |
|
19 |
18 |
$57.95 |
| D0431 |
|
31 |
26 |
$0.00 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
21 |
20 |
$0.00 |
| D0603 |
|
80 |
79 |
$0.00 |
| D0602 |
|
150 |
150 |
$0.00 |