| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
383 |
64 |
$54K |
| D9248 |
|
117 |
114 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
114 |
31 |
$9K |
| D1120 |
Prophylaxis - child |
249 |
238 |
$8K |
| D1351 |
Sealant - per tooth |
269 |
54 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
418 |
402 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
14 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
450 |
434 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
450 |
422 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
167 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
128 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
122 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0160 |
|
106 |
102 |
$2K |
| D1330 |
|
105 |
102 |
$1K |
| D0350 |
|
104 |
102 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$280.56 |
| D0602 |
|
87 |
83 |
$0.00 |
| D0601 |
|
231 |
227 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |