| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,111 |
2,697 |
$990K |
| D1120 |
Prophylaxis - child |
19,346 |
17,699 |
$595K |
| D0120 |
Periodic oral evaluation - established patient |
27,596 |
25,353 |
$567K |
| D1206 |
Topical application of fluoride varnish |
24,237 |
22,026 |
$468K |
| D1110 |
Prophylaxis - adult |
7,150 |
6,595 |
$292K |
| D0272 |
Bitewings - two radiographic images |
13,118 |
11,917 |
$279K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,758 |
1,082 |
$186K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,320 |
3,882 |
$134K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,721 |
4,204 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,120 |
1,306 |
$115K |
| D1351 |
Sealant - per tooth |
4,663 |
1,166 |
$98K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,183 |
1,483 |
$95K |
| D0330 |
Panoramic radiographic image |
1,499 |
1,378 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
1,745 |
1,571 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
2,499 |
2,181 |
$25K |
| D0240 |
|
1,895 |
1,293 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
129 |
62 |
$9K |
| D2330 |
|
83 |
48 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
130 |
116 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
378 |
184 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
13 |
$246.29 |
| D3120 |
|
67 |
54 |
$0.00 |
| D1353 |
|
20 |
12 |
$0.00 |