| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,285 |
1,059 |
$511K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,960 |
771 |
$175K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,370 |
683 |
$149K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,548 |
698 |
$102K |
| D1120 |
Prophylaxis - child |
2,861 |
2,798 |
$85K |
| D9310 |
|
1,167 |
1,135 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,212 |
2,150 |
$46K |
| D1351 |
Sealant - per tooth |
1,627 |
561 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,144 |
2,087 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,990 |
1,925 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
484 |
277 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
901 |
834 |
$24K |
| D2934 |
|
182 |
54 |
$24K |
| D0274 |
Bitewings - four radiographic images |
688 |
671 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,129 |
1,628 |
$16K |
| D3230 |
|
115 |
38 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
640 |
633 |
$10K |
| D0272 |
Bitewings - two radiographic images |
351 |
351 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
184 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$4K |
| D2335 |
|
21 |
12 |
$3K |
| D1510 |
|
17 |
12 |
$2K |
| D2330 |
|
20 |
12 |
$1K |
| D3120 |
|
36 |
28 |
$360.00 |