| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,857 |
2,554 |
$565K |
| D1120 |
Prophylaxis - child |
11,422 |
11,349 |
$563K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,787 |
3,995 |
$497K |
| D0120 |
Periodic oral evaluation - established patient |
5,599 |
5,567 |
$414K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,077 |
5,043 |
$334K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
8,178 |
7,485 |
$326K |
| D1310 |
|
5,295 |
5,253 |
$239K |
| D1351 |
Sealant - per tooth |
5,884 |
2,072 |
$209K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,512 |
2,338 |
$195K |
| D0230 |
Intraoral - periapical each additional radiographic image |
48,609 |
11,578 |
$194K |
| D1206 |
Topical application of fluoride varnish |
10,231 |
10,167 |
$187K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,305 |
2,192 |
$170K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,768 |
1,226 |
$170K |
| D1510 |
|
783 |
709 |
$151K |
| D2330 |
|
1,270 |
816 |
$94K |
| D0272 |
Bitewings - two radiographic images |
7,595 |
7,541 |
$88K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,208 |
1,203 |
$80K |
| D9430 |
|
2,405 |
2,291 |
$77K |
| D2332 |
|
710 |
467 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,185 |
2,168 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,163 |
1,158 |
$35K |
| D0603 |
|
2,365 |
2,347 |
$35K |
| D0601 |
|
2,325 |
2,306 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
217 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,812 |
1,743 |
$19K |
| D2331 |
|
114 |
83 |
$9K |
| D0602 |
|
583 |
574 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
172 |
$8K |
| D2940 |
|
71 |
57 |
$4K |
| D0350 |
|
645 |
285 |
$4K |
| D0340 |
|
62 |
62 |
$3K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$420.00 |
| D9993 |
|
82 |
82 |
$0.00 |