| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,456 |
336 |
$142K |
| D7140 |
Extraction, erupted tooth or exposed root |
990 |
358 |
$56K |
| D2934 |
|
257 |
76 |
$29K |
| D1120 |
Prophylaxis - child |
952 |
942 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
868 |
855 |
$18K |
| D1206 |
Topical application of fluoride varnish |
845 |
821 |
$16K |
| D9248 |
|
86 |
84 |
$12K |
| D0272 |
Bitewings - two radiographic images |
638 |
619 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
97 |
56 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
331 |
331 |
$6K |
| D2933 |
|
39 |
12 |
$6K |
| D0240 |
|
368 |
274 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
93 |
93 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
295 |
285 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$2K |
| D1351 |
Sealant - per tooth |
120 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
38 |
$2K |
| D1330 |
|
279 |
279 |
$1K |
| D1354 |
|
116 |
54 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
82 |
$979.89 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
15 |
$930.85 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$595.32 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$252.30 |
| D1310 |
|
13 |
13 |
$119.00 |