| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,291 |
1,946 |
$728K |
| D1120 |
Prophylaxis - child |
8,180 |
8,000 |
$412K |
| D0120 |
Periodic oral evaluation - established patient |
7,328 |
7,173 |
$167K |
| D1206 |
Topical application of fluoride varnish |
8,994 |
8,817 |
$148K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,895 |
1,269 |
$125K |
| D9248 |
|
2,701 |
2,586 |
$118K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,263 |
3,108 |
$97K |
| D0272 |
Bitewings - two radiographic images |
5,033 |
4,903 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,881 |
2,816 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,415 |
892 |
$76K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,326 |
834 |
$74K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
867 |
514 |
$55K |
| D9420 |
|
575 |
546 |
$33K |
| D0330 |
Panoramic radiographic image |
263 |
259 |
$14K |
| D9110 |
|
437 |
427 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
687 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
587 |
559 |
$7K |
| D2330 |
|
50 |
29 |
$3K |
| D1510 |
|
16 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$573.00 |
| D9630 |
|
100 |
95 |
$0.00 |
| D0603 |
|
17 |
17 |
$0.00 |