| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,035 |
521 |
$339K |
| D1120 |
Prophylaxis - child |
6,398 |
6,109 |
$242K |
| D0120 |
Periodic oral evaluation - established patient |
6,516 |
6,221 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,616 |
958 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,207 |
3,997 |
$93K |
| D1206 |
Topical application of fluoride varnish |
3,580 |
3,428 |
$91K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,223 |
1,938 |
$86K |
| D0272 |
Bitewings - two radiographic images |
3,660 |
3,473 |
$79K |
| D0145 |
Oral evaluation for a patient under three years of age |
810 |
789 |
$42K |
| D0330 |
Panoramic radiographic image |
625 |
590 |
$41K |
| D1110 |
Prophylaxis - adult |
762 |
709 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,672 |
2,502 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
347 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
307 |
158 |
$27K |
| D1351 |
Sealant - per tooth |
829 |
234 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
399 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
791 |
735 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,107 |
449 |
$7K |
| D9420 |
|
73 |
70 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$1K |
| D0240 |
|
147 |
86 |
$0.00 |