| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,960 |
970 |
$502K |
| D1120 |
Prophylaxis - child |
6,517 |
6,207 |
$232K |
| D1351 |
Sealant - per tooth |
8,093 |
1,354 |
$232K |
| D1206 |
Topical application of fluoride varnish |
7,643 |
7,256 |
$156K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,856 |
898 |
$153K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,632 |
3,431 |
$125K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,425 |
591 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
4,263 |
4,084 |
$107K |
| D0272 |
Bitewings - two radiographic images |
4,830 |
4,574 |
$105K |
| D0330 |
Panoramic radiographic image |
1,871 |
1,786 |
$93K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,902 |
2,555 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,006 |
562 |
$74K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,318 |
1,804 |
$70K |
| D0140 |
Limited oral evaluation - problem focused |
1,788 |
1,662 |
$57K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
866 |
360 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
3,744 |
3,469 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,390 |
1,310 |
$44K |
| D1110 |
Prophylaxis - adult |
836 |
806 |
$40K |
| D2934 |
|
90 |
29 |
$13K |
| D1510 |
|
22 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
99 |
$2K |
| D0240 |
|
17 |
12 |
$277.20 |
| D0460 |
|
19 |
12 |
$0.00 |