| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,763 |
686 |
$497K |
| D1120 |
Prophylaxis - child |
4,976 |
4,826 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
6,301 |
6,121 |
$169K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,319 |
6,124 |
$87K |
| D0272 |
Bitewings - two radiographic images |
3,533 |
3,405 |
$77K |
| D1110 |
Prophylaxis - adult |
1,260 |
1,237 |
$65K |
| D1351 |
Sealant - per tooth |
2,423 |
750 |
$63K |
| D0145 |
Oral evaluation for a patient under three years of age |
444 |
435 |
$61K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,878 |
1,696 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
311 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
2,611 |
2,477 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
839 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
519 |
241 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,181 |
1,840 |
$22K |
| D0274 |
Bitewings - four radiographic images |
606 |
593 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
177 |
$19K |
| D9420 |
|
274 |
266 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
79 |
39 |
$7K |
| D1206 |
Topical application of fluoride varnish |
32 |
30 |
$308.70 |
| D0603 |
|
8,102 |
7,978 |
$0.00 |