| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,702 |
978 |
$748K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,343 |
495 |
$178K |
| D0120 |
Periodic oral evaluation - established patient |
3,484 |
3,482 |
$135K |
| D7140 |
Extraction, erupted tooth or exposed root |
946 |
430 |
$97K |
| D1351 |
Sealant - per tooth |
2,027 |
472 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,046 |
1,043 |
$68K |
| D1120 |
Prophylaxis - child |
994 |
993 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
208 |
$35K |
| D9920 |
|
531 |
523 |
$31K |
| D1206 |
Topical application of fluoride varnish |
986 |
986 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,107 |
1,090 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,496 |
686 |
$21K |
| D0272 |
Bitewings - two radiographic images |
471 |
470 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
51 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
160 |
160 |
$7K |
| D2934 |
|
24 |
12 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
221 |
219 |
$0.00 |