| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
768 |
191 |
$82K |
| D1120 |
Prophylaxis - child |
1,621 |
1,598 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
820 |
811 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
369 |
109 |
$35K |
| D1310 |
|
671 |
670 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,511 |
1,836 |
$28K |
| D1206 |
Topical application of fluoride varnish |
618 |
617 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
358 |
308 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,202 |
1,190 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
174 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
138 |
52 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
899 |
876 |
$8K |
| D0603 |
|
530 |
530 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
260 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$880.00 |
| D0240 |
|
40 |
40 |
$800.00 |
| D1330 |
|
666 |
664 |
$0.00 |