| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,484 |
397 |
$168K |
| D1120 |
Prophylaxis - child |
3,168 |
3,123 |
$99K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,278 |
311 |
$99K |
| D1206 |
Topical application of fluoride varnish |
3,074 |
3,027 |
$55K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,054 |
2,756 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,458 |
1,427 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
3,102 |
3,026 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,377 |
1,366 |
$31K |
| D2934 |
|
204 |
51 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,213 |
1,195 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
700 |
675 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
193 |
78 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
140 |
$12K |
| D0274 |
Bitewings - four radiographic images |
352 |
349 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
192 |
$6K |
| D1351 |
Sealant - per tooth |
228 |
73 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
40 |
$4K |
| D9248 |
|
87 |
85 |
$2K |