| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
652 |
128 |
$127K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
43 |
$12K |
| D1120 |
Prophylaxis - child |
321 |
317 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
334 |
$11K |
| D1206 |
Topical application of fluoride varnish |
302 |
300 |
$8K |
| D0272 |
Bitewings - two radiographic images |
296 |
293 |
$5K |
| D0240 |
|
210 |
111 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
14 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
78 |
$3K |
| D1351 |
Sealant - per tooth |
65 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$859.95 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$316.20 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$157.28 |
| D9420 |
|
102 |
102 |
$0.00 |