| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,941 |
754 |
$312K |
| D1120 |
Prophylaxis - child |
6,660 |
6,525 |
$218K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,417 |
653 |
$185K |
| D0120 |
Periodic oral evaluation - established patient |
7,202 |
7,055 |
$169K |
| D1351 |
Sealant - per tooth |
5,277 |
1,609 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,745 |
6,603 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,794 |
835 |
$128K |
| D0272 |
Bitewings - two radiographic images |
5,181 |
5,076 |
$90K |
| D1110 |
Prophylaxis - adult |
2,014 |
1,966 |
$84K |
| D0330 |
Panoramic radiographic image |
1,987 |
1,937 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,051 |
539 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,509 |
1,409 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,892 |
1,850 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,126 |
1,104 |
$32K |
| D9110 |
|
627 |
600 |
$28K |
| D0274 |
Bitewings - four radiographic images |
998 |
975 |
$23K |
| D2330 |
|
329 |
103 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,515 |
1,437 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
968 |
770 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
57 |
$8K |
| D1510 |
|
47 |
39 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
275 |
261 |
$6K |
| D9248 |
|
67 |
64 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
38 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
178 |
177 |
$4K |
| D1999 |
|
444 |
350 |
$0.00 |
| D9995 |
|
23 |
12 |
$0.00 |