| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,357 |
418 |
$95K |
| D1120 |
Prophylaxis - child |
3,747 |
3,691 |
$79K |
| D1206 |
Topical application of fluoride varnish |
4,730 |
4,660 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
3,622 |
3,580 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
185 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
603 |
167 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,543 |
1,509 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
783 |
756 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
577 |
543 |
$13K |
| D9310 |
|
193 |
187 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
483 |
470 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
248 |
240 |
$5K |
| D9920 |
|
51 |
48 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
452 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
167 |
92 |
$3K |
| D0240 |
|
516 |
358 |
$3K |
| D1110 |
Prophylaxis - adult |
168 |
167 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
143 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
227 |
216 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
37 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
52 |
$578.34 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
28 |
28 |
$0.00 |