| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,615 |
726 |
$507K |
| D1120 |
Prophylaxis - child |
5,382 |
5,379 |
$219K |
| D1206 |
Topical application of fluoride varnish |
5,425 |
5,423 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
4,362 |
4,359 |
$144K |
| D0272 |
Bitewings - two radiographic images |
1,911 |
1,909 |
$49K |
| D1351 |
Sealant - per tooth |
1,569 |
499 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
536 |
246 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
702 |
702 |
$43K |
| D9420 |
|
282 |
282 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
425 |
271 |
$39K |
| D0240 |
|
1,486 |
792 |
$31K |
| D0145 |
Oral evaluation for a patient under three years of age |
372 |
372 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
94 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
154 |
154 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
195 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
518 |
$10K |
| D2390 |
|
37 |
13 |
$7K |
| D0330 |
Panoramic radiographic image |
94 |
94 |
$7K |
| D9310 |
|
39 |
39 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
41 |
$923.38 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
113 |
$0.00 |