| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
886 |
372 |
$173K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
604 |
327 |
$76K |
| D9920 |
|
1,178 |
1,121 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
644 |
312 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
837 |
795 |
$52K |
| D1120 |
Prophylaxis - child |
1,217 |
1,215 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
448 |
272 |
$42K |
| D0240 |
|
1,956 |
1,020 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,987 |
1,206 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
598 |
598 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,244 |
1,242 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,352 |
1,332 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
583 |
582 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
98 |
63 |
$13K |
| D0272 |
Bitewings - two radiographic images |
345 |
344 |
$9K |
| D1354 |
|
171 |
71 |
$5K |
| D1351 |
Sealant - per tooth |
143 |
45 |
$5K |
| D9248 |
|
75 |
63 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
98 |
98 |
$4K |
| D1510 |
|
16 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$389.76 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
185 |
182 |
$0.00 |