| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,768 |
923 |
$455K |
| D1120 |
Prophylaxis - child |
8,261 |
8,196 |
$279K |
| D0120 |
Periodic oral evaluation - established patient |
10,071 |
9,994 |
$267K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,805 |
1,154 |
$247K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,791 |
10,702 |
$209K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,410 |
1,094 |
$159K |
| D1110 |
Prophylaxis - adult |
3,345 |
3,324 |
$157K |
| D0330 |
Panoramic radiographic image |
2,446 |
2,434 |
$137K |
| D0272 |
Bitewings - two radiographic images |
5,906 |
5,869 |
$120K |
| D9248 |
|
947 |
867 |
$98K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,119 |
494 |
$97K |
| D1351 |
Sealant - per tooth |
3,612 |
1,072 |
$93K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,366 |
718 |
$84K |
| D0210 |
Intraoral - complete series of radiographic images |
1,093 |
1,078 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,094 |
1,077 |
$49K |
| D0145 |
Oral evaluation for a patient under three years of age |
785 |
781 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,476 |
2,440 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
263 |
175 |
$27K |
| D2330 |
|
164 |
103 |
$12K |
| D2390 |
|
47 |
29 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
632 |
627 |
$9K |
| D2331 |
|
17 |
12 |
$2K |
| D3110 |
|
37 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$136.62 |