| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,206 |
1,587 |
$484K |
| D1120 |
Prophylaxis - child |
11,172 |
11,110 |
$385K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,510 |
2,471 |
$278K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,941 |
1,758 |
$221K |
| D0120 |
Periodic oral evaluation - established patient |
8,270 |
8,243 |
$209K |
| D2390 |
|
1,314 |
565 |
$203K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,084 |
9,036 |
$197K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,620 |
1,469 |
$168K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,179 |
5,135 |
$149K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,803 |
4,692 |
$140K |
| D0210 |
Intraoral - complete series of radiographic images |
1,710 |
1,695 |
$102K |
| D1110 |
Prophylaxis - adult |
2,262 |
2,251 |
$87K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
964 |
555 |
$82K |
| D1206 |
Topical application of fluoride varnish |
3,787 |
3,768 |
$82K |
| D1510 |
|
441 |
369 |
$68K |
| D1351 |
Sealant - per tooth |
1,945 |
589 |
$61K |
| D2330 |
|
991 |
607 |
$60K |
| D0272 |
Bitewings - two radiographic images |
3,069 |
3,050 |
$52K |
| D0330 |
Panoramic radiographic image |
783 |
774 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,620 |
1,594 |
$35K |
| D9248 |
|
447 |
404 |
$33K |
| D1354 |
|
3,103 |
1,124 |
$28K |
| D0274 |
Bitewings - four radiographic images |
944 |
942 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,197 |
2,147 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
452 |
364 |
$4K |
| D2920 |
|
96 |
80 |
$3K |
| D2331 |
|
17 |
12 |
$1K |
| D4346 |
|
40 |
40 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0270 |
|
12 |
12 |
$70.92 |
| D9310 |
|
33 |
32 |
$0.00 |
| D9420 |
|
12 |
12 |
$0.00 |