| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
9,960 |
2,124 |
$950K |
| D1120 |
Prophylaxis - child |
28,548 |
28,008 |
$792K |
| D0120 |
Periodic oral evaluation - established patient |
35,043 |
34,439 |
$649K |
| D1208 |
Topical application of fluoride, excluding varnish |
31,198 |
30,652 |
$447K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,824 |
4,070 |
$400K |
| D0330 |
Panoramic radiographic image |
7,599 |
7,419 |
$358K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,009 |
1,972 |
$357K |
| D0272 |
Bitewings - two radiographic images |
19,630 |
19,258 |
$345K |
| D1354 |
|
13,776 |
3,162 |
$299K |
| D1110 |
Prophylaxis - adult |
8,455 |
8,320 |
$299K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,015 |
2,680 |
$297K |
| D1206 |
Topical application of fluoride varnish |
11,592 |
11,299 |
$278K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,004 |
2,298 |
$257K |
| D1351 |
Sealant - per tooth |
9,811 |
2,939 |
$225K |
| D1999 |
|
13,634 |
13,026 |
$201K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,653 |
7,158 |
$158K |
| D0220 |
Intraoral - periapical first radiographic image |
10,531 |
10,221 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,593 |
4,478 |
$112K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,066 |
5,950 |
$64K |
| D0140 |
Limited oral evaluation - problem focused |
1,526 |
1,477 |
$42K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,448 |
1,426 |
$34K |
| D2330 |
|
435 |
268 |
$23K |
| D2331 |
|
156 |
94 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$660.00 |