| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,242 |
1,296 |
$390K |
| D1120 |
Prophylaxis - child |
11,418 |
11,318 |
$332K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,637 |
1,764 |
$296K |
| D1206 |
Topical application of fluoride varnish |
13,874 |
13,737 |
$249K |
| D9920 |
|
4,130 |
3,974 |
$243K |
| D0120 |
Periodic oral evaluation - established patient |
11,822 |
11,701 |
$205K |
| D1351 |
Sealant - per tooth |
4,604 |
1,514 |
$121K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,881 |
1,199 |
$119K |
| D1110 |
Prophylaxis - adult |
2,491 |
2,463 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,325 |
3,049 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,645 |
816 |
$96K |
| D0272 |
Bitewings - two radiographic images |
4,694 |
4,647 |
$82K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
850 |
451 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,028 |
2,013 |
$56K |
| D0330 |
Panoramic radiographic image |
623 |
621 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,244 |
1,228 |
$28K |
| D9248 |
|
237 |
223 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
809 |
795 |
$17K |
| D9310 |
|
144 |
143 |
$9K |
| D9994 |
|
1,423 |
1,414 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
767 |
751 |
$7K |
| D0240 |
|
411 |
265 |
$5K |
| D3120 |
|
252 |
185 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
13 |
$261.54 |