| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,571 |
3,160 |
$905K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,925 |
4,086 |
$463K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
9,609 |
8,716 |
$427K |
| D0120 |
Periodic oral evaluation - established patient |
15,860 |
15,188 |
$412K |
| D1120 |
Prophylaxis - child |
14,887 |
14,335 |
$409K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,025 |
2,169 |
$309K |
| D1208 |
Topical application of fluoride, excluding varnish |
18,180 |
17,413 |
$303K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,684 |
2,535 |
$283K |
| D1351 |
Sealant - per tooth |
5,486 |
1,976 |
$152K |
| D1110 |
Prophylaxis - adult |
3,583 |
3,421 |
$136K |
| D0272 |
Bitewings - two radiographic images |
6,972 |
6,691 |
$129K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,652 |
2,547 |
$119K |
| D0330 |
Panoramic radiographic image |
1,791 |
1,724 |
$104K |
| D0140 |
Limited oral evaluation - problem focused |
2,417 |
2,274 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,352 |
2,655 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
4,976 |
4,725 |
$74K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,773 |
1,693 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,259 |
1,206 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,733 |
1,653 |
$28K |
| D1510 |
|
61 |
52 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
65 |
$6K |
| D2331 |
|
15 |
13 |
$1K |
| D0240 |
|
66 |
56 |
$949.87 |
| D1999 |
|
180 |
151 |
$0.00 |