| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,867 |
2,062 |
$692K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
8,117 |
3,916 |
$574K |
| D1120 |
Prophylaxis - child |
16,160 |
15,522 |
$429K |
| D0120 |
Periodic oral evaluation - established patient |
16,661 |
16,027 |
$326K |
| D1206 |
Topical application of fluoride varnish |
19,168 |
18,393 |
$306K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,276 |
1,703 |
$178K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,797 |
1,613 |
$153K |
| D0272 |
Bitewings - two radiographic images |
9,362 |
8,954 |
$149K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,805 |
7,054 |
$137K |
| D1351 |
Sealant - per tooth |
3,999 |
1,327 |
$88K |
| D0330 |
Panoramic radiographic image |
1,576 |
1,508 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,993 |
1,894 |
$51K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
720 |
360 |
$40K |
| D0240 |
|
2,772 |
2,483 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
781 |
733 |
$21K |
| D9420 |
|
646 |
611 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,791 |
1,696 |
$19K |
| D1110 |
Prophylaxis - adult |
448 |
429 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
108 |
$5K |
| D2330 |
|
100 |
51 |
$5K |
| D0251 |
|
90 |
87 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
73 |
68 |
$2K |
| D2331 |
|
21 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
36 |
$588.63 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$149.88 |
| D1330 |
|
347 |
333 |
$0.00 |