| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
658 |
120 |
$79K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
474 |
111 |
$43K |
| D1120 |
Prophylaxis - child |
477 |
476 |
$16K |
| D2933 |
|
84 |
24 |
$15K |
| D1206 |
Topical application of fluoride varnish |
444 |
443 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
273 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
146 |
115 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
116 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
248 |
248 |
$6K |
| D1351 |
Sealant - per tooth |
194 |
33 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
177 |
$4K |
| D0274 |
Bitewings - four radiographic images |
118 |
117 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
14 |
$2K |
| D1330 |
|
139 |
139 |
$875.24 |
| D1310 |
|
138 |
138 |
$873.36 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$669.44 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$567.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
37 |
$375.40 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$260.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$259.00 |
| D0601 |
|
15 |
15 |
$150.00 |