| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
675 |
197 |
$76K |
| D1120 |
Prophylaxis - child |
2,055 |
1,979 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,512 |
2,423 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,359 |
1,310 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
704 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
110 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
195 |
83 |
$17K |
| D0272 |
Bitewings - two radiographic images |
765 |
737 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
276 |
233 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
42 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
352 |
335 |
$4K |
| D2331 |
|
45 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
24 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
96 |
92 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$451.03 |
| D1354 |
|
59 |
29 |
$387.63 |
| D9420 |
|
12 |
12 |
$0.00 |