| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,610 |
1,380 |
$899K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,274 |
1,766 |
$302K |
| D1120 |
Prophylaxis - child |
6,081 |
6,080 |
$245K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,932 |
1,170 |
$229K |
| D1206 |
Topical application of fluoride varnish |
6,355 |
6,351 |
$170K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,793 |
925 |
$159K |
| D1351 |
Sealant - per tooth |
5,424 |
1,794 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
4,284 |
4,283 |
$139K |
| D2390 |
|
585 |
195 |
$119K |
| D1354 |
|
4,256 |
1,817 |
$102K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
613 |
363 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,460 |
1,455 |
$72K |
| D0140 |
Limited oral evaluation - problem focused |
1,017 |
979 |
$59K |
| D0272 |
Bitewings - two radiographic images |
3,069 |
3,059 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
2,683 |
2,617 |
$47K |
| D0240 |
|
2,041 |
1,044 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,264 |
1,120 |
$29K |
| D9310 |
|
369 |
369 |
$26K |
| D0330 |
Panoramic radiographic image |
360 |
359 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
176 |
175 |
$12K |
| D1510 |
|
35 |
25 |
$7K |
| D0274 |
Bitewings - four radiographic images |
189 |
189 |
$5K |
| D2330 |
|
49 |
40 |
$4K |
| D2331 |
|
33 |
25 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
71 |
$3K |
| D9420 |
|
16 |
13 |
$1K |
| D7111 |
|
14 |
12 |
$923.77 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,335 |
2,211 |
$0.00 |
| D1353 |
|
613 |
340 |
$0.00 |
| D3120 |
|
108 |
69 |
$0.00 |
| D0603 |
|
37 |
37 |
$0.00 |