| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,990 |
2,244 |
$678K |
| D1351 |
Sealant - per tooth |
20,115 |
5,578 |
$527K |
| D1120 |
Prophylaxis - child |
12,016 |
11,747 |
$406K |
| D0120 |
Periodic oral evaluation - established patient |
14,299 |
13,986 |
$385K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,512 |
2,387 |
$345K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,451 |
2,416 |
$314K |
| D1110 |
Prophylaxis - adult |
4,609 |
4,517 |
$237K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,588 |
6,068 |
$170K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,259 |
1,718 |
$166K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,002 |
10,737 |
$153K |
| D9248 |
|
1,175 |
1,117 |
$130K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,152 |
3,955 |
$126K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,136 |
738 |
$114K |
| D0330 |
Panoramic radiographic image |
3,387 |
3,276 |
$109K |
| D0274 |
Bitewings - four radiographic images |
3,555 |
3,473 |
$94K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,610 |
1,028 |
$92K |
| D0220 |
Intraoral - periapical first radiographic image |
7,267 |
6,911 |
$82K |
| D1206 |
Topical application of fluoride varnish |
5,642 |
5,544 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,134 |
2,081 |
$68K |
| D0272 |
Bitewings - two radiographic images |
4,051 |
3,956 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
863 |
859 |
$53K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
594 |
406 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
1,580 |
1,515 |
$30K |
| D7240 |
Removal of impacted tooth - completely bony |
89 |
26 |
$20K |
| D7111 |
|
704 |
495 |
$11K |
| D0350 |
|
837 |
497 |
$6K |
| D0603 |
|
18,463 |
18,078 |
$5K |
| D9239 |
|
33 |
28 |
$1K |
| D9243 |
|
38 |
28 |
$1K |
| D0270 |
|
164 |
160 |
$821.54 |
| D3120 |
|
15 |
12 |
$30.49 |