| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,625 |
287 |
$198K |
| D1120 |
Prophylaxis - child |
6,007 |
4,636 |
$114K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,038 |
303 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,132 |
1,952 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,918 |
2,720 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,764 |
2,013 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,605 |
2,142 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
186 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,643 |
1,723 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
572 |
444 |
$15K |
| D2934 |
|
84 |
26 |
$13K |
| D0330 |
Panoramic radiographic image |
307 |
265 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
64 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
664 |
603 |
$7K |
| D9310 |
|
142 |
137 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
44 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
103 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
288 |
263 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |