| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
775 |
183 |
$91K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
569 |
158 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
793 |
$52K |
| D1120 |
Prophylaxis - child |
961 |
958 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,230 |
1,059 |
$26K |
| D9993 |
|
379 |
379 |
$24K |
| D1351 |
Sealant - per tooth |
859 |
310 |
$19K |
| D1310 |
|
380 |
380 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
292 |
148 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
377 |
367 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
192 |
101 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
953 |
949 |
$10K |
| D2330 |
|
107 |
40 |
$8K |
| D0274 |
Bitewings - four radiographic images |
321 |
320 |
$7K |
| D0272 |
Bitewings - two radiographic images |
504 |
500 |
$6K |
| D3230 |
|
40 |
13 |
$4K |
| D0603 |
|
262 |
260 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
52 |
$2K |
| D0350 |
|
173 |
93 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
128 |
$2K |
| D2140 |
|
24 |
18 |
$1K |
| D0602 |
|
72 |
72 |
$930.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$767.00 |