| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,275 |
1,037 |
$321K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,750 |
942 |
$245K |
| D9248 |
|
2,573 |
2,418 |
$218K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,004 |
1,031 |
$176K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,002 |
644 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,677 |
2,513 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,987 |
1,987 |
$87K |
| D2934 |
|
378 |
158 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
429 |
307 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
1,703 |
1,680 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,055 |
1,055 |
$21K |
| D1120 |
Prophylaxis - child |
531 |
531 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,130 |
1,093 |
$13K |
| D1206 |
Topical application of fluoride varnish |
642 |
642 |
$11K |
| D2330 |
|
79 |
56 |
$8K |
| D1510 |
|
34 |
26 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
122 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
146 |
$4K |
| D1351 |
Sealant - per tooth |
84 |
22 |
$3K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$3K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$800.00 |