| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
260 |
105 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
160 |
68 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
44 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
253 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,352 |
1,327 |
$3K |
| D9420 |
|
14 |
13 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
139 |
79 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
638 |
612 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
721 |
691 |
$1K |
| D0603 |
|
476 |
460 |
$722.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
359 |
$663.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,353 |
1,333 |
$469.20 |
| D1120 |
Prophylaxis - child |
2,030 |
2,000 |
$464.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,975 |
1,947 |
$273.70 |
| D0601 |
|
292 |
284 |
$42.50 |
| D1330 |
|
2,228 |
2,181 |
$0.00 |
| D0602 |
|
95 |
94 |
$0.00 |