| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,891 |
1,811 |
$718K |
| D1120 |
Prophylaxis - child |
7,312 |
7,309 |
$291K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,974 |
1,241 |
$232K |
| D1206 |
Topical application of fluoride varnish |
7,411 |
7,410 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
6,159 |
6,157 |
$194K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,186 |
1,151 |
$186K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,577 |
1,110 |
$141K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
830 |
558 |
$103K |
| D0272 |
Bitewings - two radiographic images |
3,588 |
3,585 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
3,957 |
3,887 |
$70K |
| D0140 |
Limited oral evaluation - problem focused |
1,030 |
1,015 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,340 |
2,354 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
718 |
717 |
$42K |
| D1351 |
Sealant - per tooth |
623 |
245 |
$18K |
| D1354 |
|
699 |
327 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
320 |
320 |
$13K |
| D0330 |
Panoramic radiographic image |
82 |
82 |
$6K |
| D9310 |
|
75 |
75 |
$5K |
| D1510 |
|
16 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$3K |
| D2332 |
|
17 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,968 |
2,907 |
$0.00 |