| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,102 |
1,393 |
$903K |
| D1120 |
Prophylaxis - child |
13,870 |
13,870 |
$339K |
| D0120 |
Periodic oral evaluation - established patient |
16,020 |
16,020 |
$272K |
| D2932 |
|
1,329 |
338 |
$177K |
| D1206 |
Topical application of fluoride varnish |
14,396 |
14,392 |
$176K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,771 |
951 |
$169K |
| D0272 |
Bitewings - two radiographic images |
7,727 |
7,727 |
$115K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,061 |
574 |
$90K |
| D1110 |
Prophylaxis - adult |
2,320 |
2,320 |
$87K |
| D0330 |
Panoramic radiographic image |
1,710 |
1,710 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
881 |
382 |
$72K |
| D2390 |
|
331 |
82 |
$66K |
| D0140 |
Limited oral evaluation - problem focused |
1,987 |
1,971 |
$56K |
| D0240 |
|
3,074 |
1,675 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,724 |
1,724 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
765 |
714 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,323 |
1,305 |
$18K |
| D2330 |
|
209 |
94 |
$12K |
| D9310 |
|
279 |
278 |
$12K |
| D3120 |
|
306 |
192 |
$9K |
| D1351 |
Sealant - per tooth |
376 |
111 |
$8K |
| D3240 |
|
71 |
57 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
235 |
$6K |
| D0274 |
Bitewings - four radiographic images |
101 |
101 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
49 |
$548.64 |