| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,401 |
376 |
$152K |
| D1120 |
Prophylaxis - child |
3,456 |
3,456 |
$139K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,401 |
370 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,145 |
3,145 |
$85K |
| D1351 |
Sealant - per tooth |
1,737 |
535 |
$69K |
| D1206 |
Topical application of fluoride varnish |
1,867 |
1,867 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,987 |
2,985 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
708 |
443 |
$47K |
| D2331 |
|
502 |
152 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
462 |
296 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,914 |
1,914 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
805 |
805 |
$22K |
| D0330 |
Panoramic radiographic image |
490 |
490 |
$18K |
| D1110 |
Prophylaxis - adult |
206 |
206 |
$11K |
| D0240 |
|
689 |
389 |
$11K |
| D2394 |
|
68 |
40 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
651 |
643 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
55 |
$5K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$0.00 |
| D1330 |
|
174 |
174 |
$0.00 |
| D0603 |
|
164 |
164 |
$0.00 |