| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,435 |
2,734 |
$666K |
| D1120 |
Prophylaxis - child |
13,957 |
13,463 |
$447K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,926 |
2,863 |
$328K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,518 |
2,666 |
$294K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,369 |
12,894 |
$261K |
| D9248 |
|
3,537 |
3,170 |
$258K |
| D0120 |
Periodic oral evaluation - established patient |
10,899 |
10,555 |
$252K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,645 |
1,513 |
$195K |
| D8670 |
Periodic orthodontic treatment visit |
1,950 |
1,534 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,289 |
5,077 |
$143K |
| D0272 |
Bitewings - two radiographic images |
10,384 |
10,002 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,492 |
1,697 |
$136K |
| D1351 |
Sealant - per tooth |
4,437 |
1,439 |
$106K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,820 |
3,488 |
$103K |
| D0330 |
Panoramic radiographic image |
2,873 |
2,740 |
$93K |
| D1110 |
Prophylaxis - adult |
2,271 |
2,183 |
$92K |
| D0140 |
Limited oral evaluation - problem focused |
3,308 |
3,176 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
4,848 |
4,609 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,529 |
2,445 |
$48K |
| D1510 |
|
336 |
271 |
$47K |
| D2929 |
|
381 |
149 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,053 |
996 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
309 |
237 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,452 |
2,149 |
$22K |
| D2934 |
|
107 |
39 |
$11K |
| D8660 |
|
234 |
219 |
$10K |
| D2330 |
|
180 |
102 |
$9K |
| D1354 |
|
1,281 |
472 |
$7K |
| D1515 |
|
29 |
25 |
$7K |
| D0270 |
|
606 |
588 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
171 |
168 |
$3K |
| D1517 |
|
13 |
13 |
$3K |
| D9420 |
|
31 |
31 |
$30.00 |
| D1999 |
|
3,804 |
3,339 |
$0.00 |
| D9986 |
|
43 |
43 |
$0.00 |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
24 |
24 |
$0.00 |