| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,681 |
395 |
$385K |
| D1120 |
Prophylaxis - child |
3,524 |
3,316 |
$208K |
| D1351 |
Sealant - per tooth |
3,252 |
643 |
$144K |
| D1206 |
Topical application of fluoride varnish |
3,678 |
3,457 |
$96K |
| D7140 |
Extraction, erupted tooth or exposed root |
992 |
222 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
558 |
257 |
$84K |
| D0272 |
Bitewings - two radiographic images |
2,151 |
2,014 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,642 |
1,573 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,023 |
942 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
691 |
639 |
$41K |
| D0330 |
Panoramic radiographic image |
408 |
385 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,967 |
513 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
130 |
$27K |
| D0145 |
Oral evaluation for a patient under three years of age |
457 |
442 |
$25K |
| D0240 |
|
746 |
419 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
840 |
746 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
399 |
284 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
89 |
38 |
$11K |
| D0274 |
Bitewings - four radiographic images |
90 |
87 |
$5K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$3K |
| D1354 |
|
39 |
12 |
$0.00 |