| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,042 |
833 |
$581K |
| D1120 |
Prophylaxis - child |
5,181 |
5,174 |
$211K |
| D1206 |
Topical application of fluoride varnish |
5,466 |
5,459 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
4,213 |
4,208 |
$139K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,005 |
396 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
583 |
447 |
$71K |
| D9420 |
|
461 |
457 |
$63K |
| D0272 |
Bitewings - two radiographic images |
2,327 |
2,322 |
$59K |
| D1351 |
Sealant - per tooth |
1,409 |
636 |
$45K |
| D0240 |
|
1,875 |
1,262 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
667 |
659 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,214 |
1,200 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
158 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
126 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
134 |
134 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
78 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$1K |
| D1354 |
|
25 |
12 |
$720.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
682 |
662 |
$0.00 |