| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,788 |
838 |
$451K |
| D1120 |
Prophylaxis - child |
6,583 |
6,021 |
$171K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,775 |
1,714 |
$160K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,454 |
1,015 |
$149K |
| D1351 |
Sealant - per tooth |
7,008 |
2,031 |
$145K |
| D1206 |
Topical application of fluoride varnish |
7,618 |
7,011 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
7,149 |
6,614 |
$131K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,671 |
1,728 |
$117K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,217 |
3,627 |
$110K |
| D1110 |
Prophylaxis - adult |
2,701 |
2,474 |
$92K |
| D0274 |
Bitewings - four radiographic images |
2,690 |
2,476 |
$71K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
631 |
251 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
2,557 |
2,203 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,811 |
1,744 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,453 |
1,350 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,968 |
2,719 |
$27K |
| D0330 |
Panoramic radiographic image |
584 |
517 |
$25K |
| D0160 |
|
462 |
426 |
$19K |
| D1510 |
|
105 |
59 |
$18K |
| D0240 |
|
1,104 |
538 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
309 |
272 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,392 |
1,238 |
$9K |
| D1354 |
|
77 |
14 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
61 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
12 |
$532.50 |
| D1999 |
|
1,602 |
1,280 |
$290.00 |
| D3120 |
|
532 |
323 |
$0.00 |
| D9420 |
|
699 |
635 |
$0.00 |
| D0171 |
|
140 |
123 |
$0.00 |
| D9630 |
|
12 |
12 |
$0.00 |