| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,420 |
706 |
$317K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,527 |
614 |
$268K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,634 |
1,205 |
$201K |
| D0120 |
Periodic oral evaluation - established patient |
3,780 |
3,748 |
$175K |
| D1120 |
Prophylaxis - child |
4,506 |
4,476 |
$145K |
| D2335 |
|
1,166 |
254 |
$128K |
| D1351 |
Sealant - per tooth |
5,590 |
1,314 |
$125K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,770 |
5,767 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,523 |
1,510 |
$91K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,855 |
1,784 |
$68K |
| D1510 |
|
627 |
343 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,432 |
4,401 |
$48K |
| D9993 |
|
774 |
774 |
$38K |
| D0330 |
Panoramic radiographic image |
1,168 |
1,155 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,806 |
2,779 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,302 |
2,300 |
$27K |
| D1310 |
|
979 |
979 |
$13K |
| D0603 |
|
947 |
947 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
25 |
$3K |
| D9248 |
|
107 |
106 |
$3K |
| D2160 |
|
29 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$2K |
| D9920 |
|
58 |
55 |
$1K |
| D9430 |
|
44 |
37 |
$880.00 |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$847.00 |