| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,714 |
1,195 |
$884K |
| D1120 |
Prophylaxis - child |
14,170 |
12,222 |
$537K |
| D1351 |
Sealant - per tooth |
16,843 |
2,817 |
$510K |
| D0120 |
Periodic oral evaluation - established patient |
15,351 |
13,285 |
$374K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,914 |
13,780 |
$322K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,562 |
922 |
$187K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,422 |
984 |
$187K |
| D0272 |
Bitewings - two radiographic images |
7,564 |
6,534 |
$184K |
| D1110 |
Prophylaxis - adult |
2,744 |
2,420 |
$141K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,500 |
546 |
$131K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,340 |
1,924 |
$95K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
725 |
411 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
3,781 |
3,127 |
$61K |
| D9310 |
|
1,063 |
902 |
$49K |
| D0330 |
Panoramic radiographic image |
858 |
651 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
507 |
199 |
$42K |
| D9420 |
|
1,141 |
928 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,141 |
995 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,649 |
1,601 |
$37K |
| D0274 |
Bitewings - four radiographic images |
414 |
335 |
$15K |
| D1354 |
|
303 |
131 |
$12K |
| D2330 |
|
142 |
86 |
$10K |
| D1206 |
Topical application of fluoride varnish |
416 |
346 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
165 |
$7K |
| D1510 |
|
19 |
12 |
$2K |
| D2331 |
|
20 |
13 |
$2K |
| D2332 |
|
25 |
15 |
$2K |
| D9986 |
|
1,527 |
1,441 |
$0.00 |