| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,591 |
566 |
$215K |
| D1120 |
Prophylaxis - child |
7,168 |
7,051 |
$212K |
| D1206 |
Topical application of fluoride varnish |
8,031 |
7,717 |
$203K |
| D0120 |
Periodic oral evaluation - established patient |
5,823 |
5,734 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,238 |
782 |
$107K |
| D1351 |
Sealant - per tooth |
2,084 |
547 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,919 |
2,886 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,412 |
1,359 |
$46K |
| D0272 |
Bitewings - two radiographic images |
2,759 |
2,720 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
427 |
280 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
919 |
896 |
$38K |
| D1999 |
|
3,896 |
3,713 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
314 |
151 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
816 |
808 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
320 |
304 |
$17K |
| D1110 |
Prophylaxis - adult |
339 |
331 |
$12K |
| D0330 |
Panoramic radiographic image |
487 |
487 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,347 |
1,314 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,065 |
928 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
82 |
55 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
38 |
$4K |
| D9420 |
|
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
39 |
$1K |
| D0350 |
|
72 |
69 |
$0.00 |