| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,014 |
381 |
$205K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,233 |
5,368 |
$188K |
| D1120 |
Prophylaxis - child |
6,363 |
5,430 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,281 |
769 |
$107K |
| D1206 |
Topical application of fluoride varnish |
3,877 |
3,537 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
731 |
349 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,029 |
1,663 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,230 |
1,986 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
487 |
329 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,901 |
1,488 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
595 |
529 |
$14K |
| D9248 |
|
230 |
225 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
95 |
42 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
198 |
$8K |
| D0330 |
Panoramic radiographic image |
165 |
162 |
$8K |
| D0274 |
Bitewings - four radiographic images |
165 |
151 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
222 |
219 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$2K |
| D0240 |
|
32 |
26 |
$150.00 |