| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,258 |
2,092 |
$702K |
| D1120 |
Prophylaxis - child |
21,825 |
21,825 |
$623K |
| D0120 |
Periodic oral evaluation - established patient |
21,607 |
21,607 |
$431K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,651 |
2,792 |
$404K |
| D1206 |
Topical application of fluoride varnish |
24,356 |
24,356 |
$348K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,416 |
2,947 |
$336K |
| D9248 |
|
1,985 |
1,978 |
$246K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,784 |
2,470 |
$213K |
| D1351 |
Sealant - per tooth |
8,265 |
2,792 |
$188K |
| D0330 |
Panoramic radiographic image |
3,929 |
3,929 |
$180K |
| D0272 |
Bitewings - two radiographic images |
10,389 |
10,389 |
$177K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,462 |
5,427 |
$137K |
| D1110 |
Prophylaxis - adult |
2,696 |
2,696 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,541 |
2,541 |
$73K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
586 |
330 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
3,249 |
3,222 |
$46K |
| D3120 |
|
1,522 |
974 |
$43K |
| D2934 |
|
349 |
112 |
$39K |
| D0240 |
|
2,236 |
2,236 |
$38K |
| D9310 |
|
669 |
669 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
964 |
963 |
$27K |
| D2330 |
|
122 |
81 |
$7K |
| D1510 |
|
53 |
42 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
426 |
320 |
$3K |
| D1354 |
|
106 |
51 |
$2K |
| D1515 |
|
12 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$174.12 |