| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,410 |
1,362 |
$317K |
| D1120 |
Prophylaxis - child |
17,209 |
16,789 |
$227K |
| D1208 |
Topical application of fluoride, excluding varnish |
20,401 |
20,038 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
13,805 |
13,466 |
$119K |
| D0220 |
Intraoral - periapical first radiographic image |
24,128 |
23,151 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,701 |
1,905 |
$104K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,738 |
20,930 |
$97K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,260 |
654 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,772 |
5,633 |
$84K |
| D0272 |
Bitewings - two radiographic images |
10,235 |
9,914 |
$73K |
| D0274 |
Bitewings - four radiographic images |
5,894 |
5,724 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,204 |
1,295 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,556 |
679 |
$46K |
| D0330 |
Panoramic radiographic image |
3,040 |
2,960 |
$46K |
| D1110 |
Prophylaxis - adult |
1,944 |
1,892 |
$32K |
| D1351 |
Sealant - per tooth |
3,226 |
985 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,830 |
2,566 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,493 |
1,473 |
$19K |
| D2390 |
|
56 |
15 |
$7K |
| D9248 |
|
169 |
163 |
$5K |
| D2933 |
|
70 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
310 |
299 |
$2K |
| D3230 |
|
64 |
13 |
$1K |
| D1354 |
|
162 |
32 |
$478.14 |
| D3120 |
|
39 |
29 |
$364.79 |
| D0603 |
|
1,041 |
979 |
$0.00 |
| D0602 |
|
2,483 |
2,337 |
$0.00 |
| D0601 |
|
305 |
292 |
$0.00 |