| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,870 |
1,087 |
$633K |
| D1120 |
Prophylaxis - child |
5,233 |
5,221 |
$143K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,376 |
848 |
$121K |
| D1110 |
Prophylaxis - adult |
3,661 |
3,654 |
$120K |
| D1206 |
Topical application of fluoride varnish |
4,466 |
4,459 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
5,283 |
5,273 |
$82K |
| D2390 |
|
622 |
202 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,536 |
3,527 |
$31K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
216 |
103 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,799 |
1,789 |
$18K |
| D0330 |
Panoramic radiographic image |
805 |
803 |
$17K |
| D1351 |
Sealant - per tooth |
561 |
166 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
108 |
$6K |
| D9997 |
|
172 |
172 |
$5K |
| D0274 |
Bitewings - four radiographic images |
187 |
187 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
119 |
119 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
124 |
123 |
$816.20 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$37.40 |
| D9995 |
|
19 |
19 |
$0.00 |
| D1999 |
|
404 |
394 |
$0.00 |