| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,193 |
1,012 |
$492K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,694 |
506 |
$105K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,587 |
790 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,089 |
629 |
$98K |
| D2934 |
|
445 |
144 |
$78K |
| D1120 |
Prophylaxis - child |
1,941 |
1,759 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
955 |
937 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,037 |
855 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,622 |
1,437 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,333 |
1,170 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
229 |
122 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
644 |
$16K |
| D2330 |
|
207 |
132 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,458 |
1,300 |
$14K |
| D1351 |
Sealant - per tooth |
424 |
139 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,075 |
960 |
$9K |
| D0274 |
Bitewings - four radiographic images |
379 |
322 |
$8K |
| D0330 |
Panoramic radiographic image |
153 |
144 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0350 |
|
74 |
65 |
$2K |
| D1206 |
Topical application of fluoride varnish |
63 |
62 |
$2K |
| D1999 |
|
485 |
431 |
$0.00 |