| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
350 |
88 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
321 |
67 |
$49K |
| D9221 |
|
68 |
68 |
$34K |
| D1120 |
Prophylaxis - child |
365 |
365 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
207 |
101 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
53 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
229 |
$17K |
| D9220 |
|
68 |
68 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$6K |
| D1203 |
|
227 |
227 |
$5K |
| D1351 |
Sealant - per tooth |
140 |
15 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
119 |
113 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
138 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
18 |
$4K |
| D2140 |
|
46 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
169 |
$3K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$2K |