| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,742 |
609 |
$375K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,978 |
604 |
$313K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,533 |
747 |
$235K |
| D1120 |
Prophylaxis - child |
2,664 |
2,410 |
$153K |
| D7140 |
Extraction, erupted tooth or exposed root |
702 |
326 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
1,810 |
1,645 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
636 |
359 |
$80K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,341 |
1,136 |
$76K |
| D0272 |
Bitewings - two radiographic images |
2,052 |
1,849 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,002 |
881 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,864 |
1,730 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
2,233 |
1,939 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,858 |
1,344 |
$36K |
| D1330 |
|
871 |
710 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
184 |
167 |
$12K |
| D1206 |
Topical application of fluoride varnish |
293 |
261 |
$10K |
| D0330 |
Panoramic radiographic image |
64 |
61 |
$6K |
| D1351 |
Sealant - per tooth |
123 |
45 |
$4K |
| D1999 |
|
296 |
272 |
$352.00 |
| D0603 |
|
30 |
30 |
$42.12 |