| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,041 |
1,798 |
$488K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,248 |
1,871 |
$347K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,411 |
1,566 |
$232K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,327 |
1,403 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,433 |
1,516 |
$154K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,819 |
2,477 |
$71K |
| D9110 |
|
874 |
791 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,628 |
2,290 |
$41K |
| D1120 |
Prophylaxis - child |
858 |
778 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
707 |
431 |
$31K |
| D1510 |
|
304 |
252 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
722 |
$20K |
| D1351 |
Sealant - per tooth |
356 |
185 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
737 |
664 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
3,119 |
2,715 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
780 |
693 |
$14K |
| D2332 |
|
111 |
84 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
136 |
$2K |