| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,288 |
2,035 |
$682K |
| D1120 |
Prophylaxis - child |
13,192 |
13,145 |
$450K |
| D1351 |
Sealant - per tooth |
11,612 |
2,761 |
$429K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,898 |
1,528 |
$383K |
| D0120 |
Periodic oral evaluation - established patient |
14,599 |
14,555 |
$354K |
| D1110 |
Prophylaxis - adult |
6,633 |
6,612 |
$314K |
| D9248 |
|
2,108 |
2,041 |
$295K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,952 |
4,937 |
$199K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,962 |
1,133 |
$196K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,669 |
5,584 |
$196K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,851 |
1,280 |
$195K |
| D0274 |
Bitewings - four radiographic images |
6,214 |
6,194 |
$189K |
| D1206 |
Topical application of fluoride varnish |
6,417 |
6,396 |
$156K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,764 |
12,716 |
$147K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,515 |
701 |
$129K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,740 |
3,587 |
$117K |
| D0330 |
Panoramic radiographic image |
2,231 |
2,230 |
$117K |
| D0220 |
Intraoral - periapical first radiographic image |
7,750 |
7,581 |
$98K |
| D0272 |
Bitewings - two radiographic images |
3,278 |
3,267 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
1,188 |
1,171 |
$42K |
| D2934 |
|
226 |
114 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
150 |
105 |
$24K |
| D3230 |
|
94 |
48 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
256 |
243 |
$5K |
| D4346 |
|
95 |
95 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
122 |
122 |
$4K |
| D3120 |
|
79 |
64 |
$3K |