| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,983 |
1,529 |
$698K |
| D1351 |
Sealant - per tooth |
14,921 |
3,082 |
$421K |
| D1120 |
Prophylaxis - child |
11,815 |
11,600 |
$324K |
| D0120 |
Periodic oral evaluation - established patient |
11,171 |
11,035 |
$293K |
| D1206 |
Topical application of fluoride varnish |
13,800 |
13,557 |
$225K |
| D0240 |
|
8,906 |
4,514 |
$144K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,115 |
2,880 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,773 |
980 |
$138K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,284 |
2,209 |
$101K |
| D0272 |
Bitewings - two radiographic images |
4,919 |
4,839 |
$91K |
| D0330 |
Panoramic radiographic image |
1,567 |
1,536 |
$91K |
| D1110 |
Prophylaxis - adult |
2,181 |
2,145 |
$83K |
| D0140 |
Limited oral evaluation - problem focused |
1,932 |
1,832 |
$71K |
| D7140 |
Extraction, erupted tooth or exposed root |
964 |
498 |
$59K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
684 |
339 |
$54K |
| D0274 |
Bitewings - four radiographic images |
825 |
814 |
$27K |
| D9420 |
|
160 |
154 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
60 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
272 |
172 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
413 |
388 |
$6K |
| D9110 |
|
14 |
14 |
$623.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
12 |
$268.32 |