| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
785 |
124 |
$89K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
396 |
98 |
$33K |
| D9610 |
|
181 |
181 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
24 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
16 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
107 |
107 |
$2K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
127 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
124 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$676.50 |
| D0140 |
Limited oral evaluation - problem focused |
23 |
23 |
$648.60 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$406.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$329.81 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
18 |
$133.95 |