| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
7,554 |
1,956 |
$994K |
| D1120 |
Prophylaxis - child |
12,421 |
12,272 |
$423K |
| D0120 |
Periodic oral evaluation - established patient |
12,544 |
12,421 |
$347K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,799 |
1,315 |
$345K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,469 |
1,927 |
$250K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,278 |
11,138 |
$223K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,992 |
1,081 |
$162K |
| D0272 |
Bitewings - two radiographic images |
6,674 |
6,528 |
$137K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,964 |
1,098 |
$127K |
| D9420 |
|
1,350 |
1,210 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,071 |
2,801 |
$101K |
| D1206 |
Topical application of fluoride varnish |
3,829 |
3,806 |
$94K |
| D1351 |
Sealant - per tooth |
2,361 |
686 |
$75K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,611 |
1,604 |
$70K |
| D1110 |
Prophylaxis - adult |
1,513 |
1,489 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,417 |
1,380 |
$65K |
| D9248 |
|
819 |
599 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
4,142 |
3,876 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
2,562 |
2,489 |
$36K |
| D2934 |
|
118 |
36 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,547 |
1,282 |
$16K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$6K |
| D2330 |
|
78 |
36 |
$4K |
| D0274 |
Bitewings - four radiographic images |
17 |
16 |
$0.00 |