| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
882 |
201 |
$119K |
| D1351 |
Sealant - per tooth |
765 |
227 |
$20K |
| D9248 |
|
136 |
128 |
$14K |
| D1120 |
Prophylaxis - child |
357 |
353 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
391 |
385 |
$11K |
| D2140 |
|
147 |
92 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
183 |
$6K |
| D0272 |
Bitewings - two radiographic images |
278 |
272 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
59 |
30 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
332 |
329 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
235 |
225 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
116 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
33 |
$867.52 |
| D0330 |
Panoramic radiographic image |
27 |
25 |
$750.50 |
| D9420 |
|
16 |
15 |
$541.86 |
| D1206 |
Topical application of fluoride varnish |
34 |
32 |
$279.30 |
| D0603 |
|
679 |
658 |
$0.00 |