| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,112 |
669 |
$291K |
| D1120 |
Prophylaxis - child |
5,893 |
5,523 |
$188K |
| D1206 |
Topical application of fluoride varnish |
5,628 |
5,272 |
$180K |
| D0120 |
Periodic oral evaluation - established patient |
5,701 |
5,375 |
$172K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,710 |
581 |
$144K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,390 |
602 |
$95K |
| D1110 |
Prophylaxis - adult |
1,905 |
1,781 |
$87K |
| D1351 |
Sealant - per tooth |
2,582 |
1,034 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,034 |
2,815 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,727 |
2,456 |
$59K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
649 |
324 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
778 |
499 |
$58K |
| D0240 |
|
3,170 |
1,723 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
960 |
875 |
$39K |
| D9248 |
|
387 |
339 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,563 |
1,463 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
185 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
745 |
659 |
$23K |
| D9420 |
|
160 |
146 |
$23K |
| D0274 |
Bitewings - four radiographic images |
696 |
650 |
$22K |
| D0330 |
Panoramic radiographic image |
438 |
404 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
930 |
757 |
$14K |
| D1330 |
|
1,637 |
1,498 |
$9K |
| D2140 |
|
26 |
25 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
124 |
106 |
$4K |
| D3120 |
|
130 |
77 |
$3K |
| D9310 |
|
18 |
14 |
$853.16 |
| D1310 |
|
14 |
13 |
$134.09 |
| D1300 |
|
14 |
14 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
17 |
15 |
$0.00 |