| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,067 |
486 |
$211K |
| D1120 |
Prophylaxis - child |
3,811 |
3,808 |
$160K |
| D1206 |
Topical application of fluoride varnish |
3,927 |
3,925 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
496 |
311 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
825 |
824 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
506 |
295 |
$44K |
| D1354 |
|
1,496 |
368 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
694 |
$24K |
| D0272 |
Bitewings - two radiographic images |
880 |
879 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,074 |
1,018 |
$21K |
| D9310 |
|
277 |
277 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
120 |
$18K |
| D9248 |
|
260 |
249 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
109 |
85 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
657 |
446 |
$9K |
| D1352 |
|
135 |
55 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
195 |
194 |
$8K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$6K |
| D0240 |
|
57 |
43 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$845.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$616.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
190 |
182 |
$0.00 |
| D3120 |
|
124 |
80 |
$0.00 |