| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,745 |
1,957 |
$758K |
| D1120 |
Prophylaxis - child |
12,682 |
12,296 |
$664K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,335 |
2,397 |
$352K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
8,830 |
8,561 |
$251K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,195 |
13,767 |
$220K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,417 |
1,795 |
$191K |
| D0330 |
Panoramic radiographic image |
3,555 |
3,441 |
$166K |
| D1351 |
Sealant - per tooth |
7,629 |
2,281 |
$156K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,116 |
3,790 |
$147K |
| D0272 |
Bitewings - two radiographic images |
7,049 |
6,787 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
5,744 |
5,578 |
$130K |
| D9248 |
|
1,949 |
1,824 |
$127K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,785 |
837 |
$113K |
| D1110 |
Prophylaxis - adult |
1,561 |
1,531 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
7,404 |
6,736 |
$74K |
| D0140 |
Limited oral evaluation - problem focused |
1,744 |
1,624 |
$61K |
| D2332 |
|
710 |
455 |
$59K |
| D2335 |
|
578 |
237 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,536 |
1,488 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,463 |
2,409 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
405 |
235 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
136 |
99 |
$11K |
| D9986 |
|
1,384 |
1,149 |
$0.00 |
| D9987 |
|
305 |
266 |
$0.00 |