| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,821 |
978 |
$576K |
| D8670 |
Periodic orthodontic treatment visit |
4,970 |
4,929 |
$505K |
| D1120 |
Prophylaxis - child |
7,174 |
7,008 |
$181K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,591 |
3,130 |
$146K |
| D1206 |
Topical application of fluoride varnish |
8,129 |
7,944 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
6,845 |
6,690 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,803 |
823 |
$117K |
| D1351 |
Sealant - per tooth |
3,988 |
1,300 |
$86K |
| D0272 |
Bitewings - two radiographic images |
4,645 |
4,543 |
$77K |
| D9420 |
|
354 |
339 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
657 |
646 |
$14K |
| D0240 |
|
939 |
543 |
$13K |
| D1354 |
|
1,831 |
510 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
724 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
24 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
38 |
$895.56 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$262.25 |
| D3120 |
|
143 |
61 |
$0.00 |