| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
552 |
173 |
$66K |
| D9248 |
|
709 |
521 |
$44K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
559 |
175 |
$44K |
| D1120 |
Prophylaxis - child |
860 |
843 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
276 |
105 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,070 |
1,049 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
491 |
$19K |
| D1206 |
Topical application of fluoride varnish |
909 |
900 |
$18K |
| D0274 |
Bitewings - four radiographic images |
350 |
343 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
68 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
339 |
335 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
13 |
$8K |
| D0330 |
Panoramic radiographic image |
158 |
150 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
245 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
129 |
123 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
562 |
515 |
$7K |
| D4341 |
|
12 |
12 |
$7K |
| D3230 |
|
43 |
13 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
161 |
122 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
77 |
$3K |
| D1351 |
Sealant - per tooth |
89 |
31 |
$2K |