| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,131 |
225 |
$85K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
243 |
85 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
334 |
156 |
$9K |
| D1120 |
Prophylaxis - child |
1,934 |
1,924 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
56 |
$6K |
| D2934 |
|
37 |
12 |
$5K |
| D1206 |
Topical application of fluoride varnish |
2,201 |
2,190 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
499 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,958 |
953 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,052 |
1,034 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,281 |
1,262 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,003 |
1,001 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
34 |
$768.51 |
| D0274 |
Bitewings - four radiographic images |
290 |
288 |
$580.86 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
115 |
110 |
$560.24 |
| D1351 |
Sealant - per tooth |
169 |
59 |
$443.46 |
| D0350 |
|
48 |
48 |
$312.00 |
| D1354 |
|
69 |
15 |
$307.84 |
| D0145 |
Oral evaluation for a patient under three years of age |
51 |
51 |
$258.78 |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$233.21 |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$183.58 |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
49 |
$132.64 |
| D0601 |
|
93 |
92 |
$0.00 |
| D0603 |
|
592 |
566 |
$0.00 |
| D0602 |
|
36 |
36 |
$0.00 |