| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,887 |
1,450 |
$858K |
| D1120 |
Prophylaxis - child |
6,743 |
6,649 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
5,096 |
5,051 |
$126K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,606 |
1,524 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,657 |
1,603 |
$69K |
| D1206 |
Topical application of fluoride varnish |
4,257 |
4,206 |
$68K |
| D2934 |
|
361 |
70 |
$67K |
| D9420 |
|
458 |
450 |
$56K |
| D1351 |
Sealant - per tooth |
2,051 |
659 |
$55K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
618 |
277 |
$53K |
| D0330 |
Panoramic radiographic image |
792 |
777 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
379 |
210 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
2,787 |
2,727 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,406 |
2,361 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,583 |
2,542 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
925 |
882 |
$34K |
| D2929 |
|
165 |
32 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
348 |
151 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,023 |
560 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,136 |
513 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
56 |
$13K |
| D2332 |
|
78 |
42 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$2K |
| D1354 |
|
269 |
111 |
$2K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D9971 |
|
130 |
36 |
$0.00 |
| D1999 |
|
4,684 |
4,526 |
$0.00 |
| D9219 |
|
533 |
522 |
$0.00 |
| D9990 |
|
2,182 |
2,086 |
$0.00 |
| D0350 |
|
9,073 |
8,576 |
$0.00 |
| D1310 |
|
7,361 |
7,252 |
$0.00 |
| D0602 |
|
278 |
276 |
$0.00 |
| D1330 |
|
7,362 |
7,255 |
$0.00 |
| D0601 |
|
1,087 |
1,054 |
$0.00 |
| D0603 |
|
5,721 |
5,652 |
$0.00 |
| D9995 |
|
297 |
290 |
$0.00 |
| D9994 |
|
134 |
128 |
$0.00 |
| D3120 |
|
108 |
40 |
$0.00 |
| D1320 |
|
113 |
110 |
$0.00 |
| D0171 |
|
13 |
13 |
$0.00 |