| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,829 |
319 |
$240K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,032 |
268 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
116 |
$18K |
| D1351 |
Sealant - per tooth |
654 |
212 |
$16K |
| D2934 |
|
105 |
29 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
57 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
328 |
$11K |
| D0272 |
Bitewings - two radiographic images |
464 |
430 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
73 |
$8K |
| D9420 |
|
234 |
218 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
721 |
375 |
$7K |
| D1120 |
Prophylaxis - child |
219 |
208 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
254 |
232 |
$6K |
| D0350 |
|
372 |
332 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
202 |
196 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
472 |
437 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
243 |
$3K |
| D0160 |
|
163 |
158 |
$2K |
| D2330 |
|
23 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$995.34 |
| D0603 |
|
820 |
744 |
$0.00 |