| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,343 |
1,187 |
$718K |
| D1120 |
Prophylaxis - child |
9,041 |
8,760 |
$275K |
| D0120 |
Periodic oral evaluation - established patient |
10,045 |
9,752 |
$216K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,675 |
1,148 |
$205K |
| D1206 |
Topical application of fluoride varnish |
11,128 |
10,785 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,735 |
980 |
$142K |
| D0272 |
Bitewings - two radiographic images |
6,058 |
5,860 |
$120K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,296 |
760 |
$86K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,870 |
2,502 |
$79K |
| D1110 |
Prophylaxis - adult |
1,780 |
1,730 |
$76K |
| D0330 |
Panoramic radiographic image |
1,467 |
1,413 |
$68K |
| D1351 |
Sealant - per tooth |
2,412 |
705 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,611 |
1,536 |
$48K |
| D2390 |
|
345 |
83 |
$48K |
| D9420 |
|
606 |
557 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,305 |
3,008 |
$41K |
| D9310 |
|
395 |
388 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
292 |
123 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
467 |
445 |
$13K |
| D1510 |
|
39 |
26 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$905.23 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
42 |
$602.84 |