| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,592 |
268 |
$292K |
| D1120 |
Prophylaxis - child |
4,823 |
4,567 |
$238K |
| D1206 |
Topical application of fluoride varnish |
6,850 |
6,495 |
$197K |
| D0120 |
Periodic oral evaluation - established patient |
5,101 |
4,915 |
$183K |
| D9420 |
|
546 |
464 |
$152K |
| D7140 |
Extraction, erupted tooth or exposed root |
948 |
251 |
$104K |
| D0272 |
Bitewings - two radiographic images |
2,602 |
2,458 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,053 |
1,004 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
671 |
587 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
65 |
$24K |
| D0330 |
Panoramic radiographic image |
286 |
275 |
$23K |
| D0240 |
|
556 |
280 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
829 |
282 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
622 |
505 |
$13K |
| D1351 |
Sealant - per tooth |
411 |
88 |
$12K |
| D1110 |
Prophylaxis - adult |
159 |
154 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
24 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
14 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |
| D3120 |
|
18 |
12 |
$0.00 |