| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
832 |
370 |
$173K |
| D1120 |
Prophylaxis - child |
2,399 |
2,396 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,110 |
1,976 |
$85K |
| D1206 |
Topical application of fluoride varnish |
2,402 |
2,395 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,494 |
1,492 |
$56K |
| D9920 |
|
874 |
862 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
763 |
740 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
2,342 |
2,321 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
358 |
198 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
272 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
100 |
$16K |
| D0240 |
|
938 |
578 |
$16K |
| D1351 |
Sealant - per tooth |
331 |
126 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
318 |
280 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
25 |
$5K |
| D1354 |
|
91 |
55 |
$3K |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
50 |
50 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$2K |
| D1999 |
|
171 |
164 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
196 |
184 |
$0.00 |
| D9986 |
|
75 |
73 |
$0.00 |