| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,794 |
694 |
$319K |
| D1120 |
Prophylaxis - child |
5,173 |
5,027 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
5,040 |
4,890 |
$144K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,198 |
6,033 |
$141K |
| D9248 |
|
661 |
613 |
$119K |
| D0272 |
Bitewings - two radiographic images |
3,401 |
3,285 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,258 |
1,232 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,009 |
925 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
527 |
188 |
$37K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
20 |
20 |
$31K |
| D0330 |
Panoramic radiographic image |
508 |
493 |
$26K |
| D8670 |
Periodic orthodontic treatment visit |
907 |
884 |
$24K |
| D1110 |
Prophylaxis - adult |
365 |
345 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
67 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
615 |
586 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
49 |
$6K |
| D9310 |
|
68 |
67 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$600.98 |