| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,049 |
193 |
$126K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
766 |
192 |
$124K |
| D1110 |
Prophylaxis - adult |
1,281 |
1,281 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,227 |
1,225 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
350 |
184 |
$24K |
| D0274 |
Bitewings - four radiographic images |
802 |
802 |
$19K |
| D0330 |
Panoramic radiographic image |
588 |
587 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
799 |
657 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,087 |
1,076 |
$11K |
| D1120 |
Prophylaxis - child |
270 |
270 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
328 |
$9K |
| D9420 |
|
81 |
81 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
44 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
291 |
291 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
33 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
195 |
194 |
$3K |
| D1351 |
Sealant - per tooth |
50 |
16 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
29 |
$1K |
| D2331 |
|
18 |
14 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$312.50 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$280.00 |
| D0270 |
|
13 |
13 |
$102.60 |
| D1999 |
|
20 |
19 |
$0.00 |