| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,924 |
971 |
$557K |
| D1120 |
Prophylaxis - child |
5,397 |
5,091 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
4,721 |
4,491 |
$113K |
| D1206 |
Topical application of fluoride varnish |
5,647 |
5,335 |
$84K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
556 |
279 |
$73K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
816 |
347 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,025 |
381 |
$64K |
| D1351 |
Sealant - per tooth |
2,263 |
687 |
$62K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,327 |
1,262 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
3,227 |
3,044 |
$45K |
| D0330 |
Panoramic radiographic image |
783 |
752 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
966 |
905 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,416 |
2,296 |
$40K |
| D2335 |
|
308 |
142 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
156 |
$29K |
| D9420 |
|
208 |
205 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,113 |
805 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
504 |
471 |
$18K |
| D2332 |
|
171 |
89 |
$17K |
| D1110 |
Prophylaxis - adult |
278 |
273 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
425 |
225 |
$8K |
| D2929 |
|
44 |
15 |
$7K |
| D2940 |
|
42 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$771.65 |
| D1330 |
|
4,730 |
4,394 |
$0.00 |
| D1310 |
|
4,728 |
4,392 |
$0.00 |
| D0603 |
|
4,524 |
4,216 |
$0.00 |
| D1320 |
|
92 |
92 |
$0.00 |
| D9995 |
|
36 |
36 |
$0.00 |
| D9990 |
|
1,738 |
1,565 |
$0.00 |
| D0350 |
|
6,327 |
5,700 |
$0.00 |
| D1999 |
|
7,527 |
6,762 |
$0.00 |
| D9971 |
|
45 |
15 |
$0.00 |
| D9219 |
|
312 |
307 |
$0.00 |