| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,106 |
1,533 |
$609K |
| D1120 |
Prophylaxis - child |
10,007 |
10,003 |
$436K |
| D1206 |
Topical application of fluoride varnish |
9,502 |
9,498 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
7,201 |
7,200 |
$254K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,965 |
1,230 |
$249K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,370 |
1,463 |
$234K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,183 |
1,310 |
$197K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,116 |
4,931 |
$178K |
| D0220 |
Intraoral - periapical first radiographic image |
6,280 |
6,235 |
$121K |
| D1351 |
Sealant - per tooth |
3,479 |
1,274 |
$102K |
| D0140 |
Limited oral evaluation - problem focused |
1,558 |
1,552 |
$97K |
| D9310 |
|
1,148 |
1,147 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,362 |
1,362 |
$86K |
| D0272 |
Bitewings - two radiographic images |
3,274 |
3,274 |
$85K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,046 |
1,045 |
$43K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
181 |
117 |
$23K |
| D9248 |
|
343 |
340 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
400 |
400 |
$12K |
| D0240 |
|
227 |
226 |
$5K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
37 |
$3K |
| D1354 |
|
34 |
12 |
$896.46 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$870.00 |