| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,209 |
242 |
$304K |
| D7140 |
Extraction, erupted tooth or exposed root |
609 |
156 |
$87K |
| D9420 |
|
195 |
183 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,719 |
376 |
$35K |
| D1120 |
Prophylaxis - child |
685 |
663 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
71 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
305 |
295 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
210 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
604 |
512 |
$18K |
| D1206 |
Topical application of fluoride varnish |
611 |
577 |
$16K |
| D0272 |
Bitewings - two radiographic images |
489 |
431 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
534 |
534 |
$13K |
| D1351 |
Sealant - per tooth |
33 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$242.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
24 |
12 |
$0.00 |