| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,120 |
184 |
$122K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
846 |
198 |
$68K |
| D1120 |
Prophylaxis - child |
1,986 |
1,986 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
2,128 |
2,128 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,033 |
2,033 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,017 |
1,017 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
299 |
298 |
$8K |
| D1351 |
Sealant - per tooth |
403 |
187 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
306 |
293 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
287 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
41 |
26 |
$2K |
| D0240 |
|
135 |
85 |
$2K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
20 |
$1K |