| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
982 |
195 |
$89K |
| D1120 |
Prophylaxis - child |
1,614 |
1,537 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
445 |
133 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,478 |
1,449 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
808 |
786 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
294 |
116 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
616 |
611 |
$11K |
| D0272 |
Bitewings - two radiographic images |
1,114 |
1,068 |
$11K |
| D2335 |
|
113 |
39 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
89 |
$10K |
| D0240 |
|
769 |
311 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
197 |
$4K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$4K |
| D1351 |
Sealant - per tooth |
113 |
39 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
30 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
32 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
60 |
$1K |
| D1354 |
|
55 |
13 |
$780.00 |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
145 |
$710.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
50 |
$370.00 |
| D1999 |
|
15 |
15 |
$0.00 |
| D9215 |
|
33 |
32 |
$0.00 |