| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,161 |
1,009 |
$336K |
| D1120 |
Prophylaxis - child |
10,130 |
9,993 |
$330K |
| D1206 |
Topical application of fluoride varnish |
10,346 |
10,199 |
$195K |
| D0120 |
Periodic oral evaluation - established patient |
7,981 |
7,907 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,379 |
823 |
$138K |
| D0272 |
Bitewings - two radiographic images |
4,906 |
4,845 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
941 |
670 |
$69K |
| D1351 |
Sealant - per tooth |
2,767 |
825 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
702 |
369 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,465 |
2,418 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,012 |
981 |
$33K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,064 |
1,042 |
$29K |
| D0330 |
Panoramic radiographic image |
541 |
540 |
$29K |
| D9310 |
|
338 |
331 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
403 |
$5K |
| D9420 |
|
114 |
114 |
$4K |
| D0240 |
|
204 |
190 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
47 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$719.02 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$435.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
13 |
$232.65 |
| D1330 |
|
2,885 |
2,788 |
$0.00 |