| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
458 |
197 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
529 |
284 |
$64K |
| D1120 |
Prophylaxis - child |
1,369 |
1,369 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
418 |
253 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,187 |
1,187 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
469 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
362 |
360 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
659 |
658 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
255 |
155 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
911 |
902 |
$17K |
| D0272 |
Bitewings - two radiographic images |
634 |
634 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
129 |
76 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,092 |
709 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
190 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
115 |
115 |
$5K |
| D1354 |
|
139 |
58 |
$4K |
| D0240 |
|
36 |
24 |
$770.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
251 |
245 |
$0.00 |