| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
600 |
214 |
$74K |
| D9248 |
|
285 |
270 |
$39K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
407 |
152 |
$35K |
| D1120 |
Prophylaxis - child |
771 |
747 |
$23K |
| D1351 |
Sealant - per tooth |
547 |
140 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
753 |
731 |
$17K |
| D2934 |
|
81 |
30 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
248 |
$10K |
| D1110 |
Prophylaxis - adult |
245 |
232 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
333 |
317 |
$9K |
| D0330 |
Panoramic radiographic image |
170 |
159 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
723 |
699 |
$8K |
| D0274 |
Bitewings - four radiographic images |
262 |
246 |
$7K |
| D0272 |
Bitewings - two radiographic images |
290 |
279 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
41 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
445 |
426 |
$5K |
| D1206 |
Topical application of fluoride varnish |
296 |
285 |
$5K |
| D3230 |
|
32 |
12 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
64 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$848.90 |