| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,883 |
2,619 |
$753K |
| D1120 |
Prophylaxis - child |
16,726 |
16,726 |
$583K |
| D0120 |
Periodic oral evaluation - established patient |
15,712 |
15,712 |
$367K |
| D1206 |
Topical application of fluoride varnish |
21,668 |
21,668 |
$355K |
| D1110 |
Prophylaxis - adult |
5,123 |
5,123 |
$258K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,568 |
1,341 |
$235K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,646 |
4,646 |
$192K |
| D0330 |
Panoramic radiographic image |
3,355 |
3,355 |
$169K |
| D0272 |
Bitewings - two radiographic images |
8,714 |
8,714 |
$166K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,965 |
4,697 |
$161K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,396 |
981 |
$110K |
| D0274 |
Bitewings - four radiographic images |
3,603 |
3,603 |
$101K |
| D2140 |
|
1,506 |
1,087 |
$91K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,905 |
1,905 |
$83K |
| D1351 |
Sealant - per tooth |
1,918 |
789 |
$57K |
| D7111 |
|
851 |
598 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
576 |
420 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
2,899 |
2,857 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
183 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
577 |
576 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
760 |
398 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
60 |
38 |
$5K |
| D9920 |
|
52 |
52 |
$3K |
| D9310 |
|
14 |
14 |
$882.00 |