| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
262 |
38 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
241 |
40 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
208 |
$12K |
| D1120 |
Prophylaxis - child |
263 |
143 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
150 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
43 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
214 |
86 |
$2K |
| D1351 |
Sealant - per tooth |
88 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
124 |
37 |
$992.00 |
| D3120 |
|
45 |
12 |
$902.00 |
| D0120 |
Periodic oral evaluation - established patient |
50 |
25 |
$768.00 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
39 |
$765.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
36 |
$680.00 |