| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,319 |
1,532 |
$681K |
| D1120 |
Prophylaxis - child |
14,734 |
14,693 |
$592K |
| D0120 |
Periodic oral evaluation - established patient |
15,298 |
15,253 |
$446K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,718 |
2,235 |
$335K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,657 |
13,622 |
$243K |
| D0272 |
Bitewings - two radiographic images |
7,859 |
7,815 |
$172K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,229 |
1,300 |
$134K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,479 |
798 |
$130K |
| D1351 |
Sealant - per tooth |
4,251 |
1,488 |
$116K |
| D0330 |
Panoramic radiographic image |
1,912 |
1,903 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,187 |
713 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,086 |
2,076 |
$81K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,536 |
3,301 |
$71K |
| D9248 |
|
390 |
372 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
1,168 |
1,118 |
$46K |
| D0240 |
|
2,566 |
2,287 |
$45K |
| D0603 |
|
4,749 |
4,733 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,932 |
1,924 |
$35K |
| D1110 |
Prophylaxis - adult |
245 |
245 |
$13K |
| D0602 |
|
979 |
978 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
493 |
$6K |
| D0601 |
|
288 |
288 |
$3K |
| D2330 |
|
46 |
28 |
$3K |
| D1354 |
|
41 |
22 |
$444.80 |