| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,162 |
1,040 |
$289K |
| D1120 |
Prophylaxis - child |
14,435 |
13,274 |
$242K |
| D0120 |
Periodic oral evaluation - established patient |
18,554 |
16,945 |
$227K |
| D1110 |
Prophylaxis - adult |
7,537 |
6,992 |
$200K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,169 |
15,636 |
$188K |
| D1351 |
Sealant - per tooth |
8,881 |
3,150 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,577 |
2,285 |
$121K |
| D0330 |
Panoramic radiographic image |
3,416 |
3,079 |
$113K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,523 |
1,341 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,448 |
2,162 |
$93K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,425 |
698 |
$85K |
| D0272 |
Bitewings - two radiographic images |
5,181 |
4,705 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,127 |
2,848 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
2,570 |
2,337 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,627 |
2,368 |
$48K |
| D2330 |
|
944 |
596 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,307 |
1,988 |
$36K |
| D2331 |
|
692 |
478 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,467 |
1,326 |
$28K |
| D1510 |
|
210 |
141 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
455 |
379 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,195 |
1,933 |
$14K |
| D0240 |
|
1,038 |
767 |
$11K |
| D2335 |
|
201 |
149 |
$10K |
| D2332 |
|
231 |
162 |
$10K |
| D2934 |
|
146 |
38 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,615 |
599 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
341 |
263 |
$6K |
| D7111 |
|
114 |
80 |
$5K |
| D0270 |
|
57 |
55 |
$556.83 |
| D2920 |
|
14 |
14 |
$0.00 |