| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
730 |
490 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,462 |
1,390 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,252 |
750 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
705 |
447 |
$73K |
| D1120 |
Prophylaxis - child |
1,189 |
1,181 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
680 |
461 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
644 |
419 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,486 |
1,482 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,397 |
2,150 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,176 |
1,168 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,004 |
997 |
$29K |
| D1351 |
Sealant - per tooth |
450 |
192 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,450 |
2,417 |
$16K |
| D1354 |
|
600 |
249 |
$12K |
| D2394 |
|
74 |
61 |
$7K |
| D0274 |
Bitewings - four radiographic images |
330 |
330 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
230 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
75 |
$4K |
| D0272 |
Bitewings - two radiographic images |
279 |
274 |
$3K |
| D2335 |
|
17 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$822.46 |
| D9110 |
|
13 |
13 |
$715.00 |