| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
139 |
60 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
152 |
61 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
50 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
42 |
$5K |
| D9248 |
|
84 |
82 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
35 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
91 |
89 |
$3K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$2K |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
101 |
$1K |
| D1110 |
Prophylaxis - adult |
21 |
21 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
43 |
$931.20 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$757.60 |
| D0274 |
Bitewings - four radiographic images |
23 |
23 |
$632.73 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$570.81 |