| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,118 |
929 |
$487K |
| D1120 |
Prophylaxis - child |
6,541 |
6,500 |
$321K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,698 |
849 |
$265K |
| D0120 |
Periodic oral evaluation - established patient |
3,100 |
3,073 |
$203K |
| D1310 |
|
4,348 |
4,331 |
$192K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,469 |
2,454 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,490 |
828 |
$165K |
| D1206 |
Topical application of fluoride varnish |
6,524 |
6,483 |
$138K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,657 |
723 |
$94K |
| D1351 |
Sealant - per tooth |
2,358 |
639 |
$90K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,097 |
1,095 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,438 |
3,118 |
$72K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,603 |
1,536 |
$63K |
| D0603 |
|
4,344 |
4,327 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
2,584 |
2,568 |
$31K |
| D9430 |
|
500 |
460 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
283 |
130 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
151 |
78 |
$12K |
| D2330 |
|
60 |
31 |
$5K |
| D0330 |
Panoramic radiographic image |
128 |
102 |
$4K |
| D0274 |
Bitewings - four radiographic images |
153 |
142 |
$3K |
| D0340 |
|
127 |
101 |
$3K |
| D0272 |
Bitewings - two radiographic images |
115 |
113 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$528.00 |
| D9993 |
|
4,338 |
4,321 |
$0.00 |