| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,582 |
262 |
$186K |
| D1120 |
Prophylaxis - child |
5,907 |
5,747 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
5,501 |
5,332 |
$133K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,376 |
5,225 |
$95K |
| D0272 |
Bitewings - two radiographic images |
3,020 |
2,950 |
$56K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
477 |
180 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
500 |
188 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
598 |
590 |
$26K |
| D9420 |
|
235 |
220 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,192 |
1,166 |
$16K |
| D9248 |
|
168 |
120 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
203 |
201 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
56 |
$9K |
| D1110 |
Prophylaxis - adult |
183 |
167 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
417 |
381 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
77 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
50 |
$683.10 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$570.50 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$242.90 |