| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,846 |
1,597 |
$418K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,634 |
1,771 |
$369K |
| D1120 |
Prophylaxis - child |
9,698 |
9,419 |
$319K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,577 |
2,514 |
$268K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,494 |
1,823 |
$244K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,220 |
9,937 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
8,766 |
8,504 |
$209K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,606 |
1,158 |
$145K |
| D9248 |
|
1,331 |
1,277 |
$108K |
| D1351 |
Sealant - per tooth |
3,395 |
1,167 |
$99K |
| D0272 |
Bitewings - two radiographic images |
5,148 |
4,995 |
$85K |
| D1110 |
Prophylaxis - adult |
1,886 |
1,828 |
$79K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,831 |
2,647 |
$79K |
| D0330 |
Panoramic radiographic image |
1,730 |
1,692 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,395 |
2,323 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
2,562 |
2,439 |
$58K |
| D2330 |
|
944 |
447 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,100 |
2,043 |
$43K |
| D2929 |
|
198 |
61 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
891 |
870 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,590 |
887 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,735 |
1,645 |
$20K |
| D1510 |
|
92 |
62 |
$13K |
| D1354 |
|
1,682 |
591 |
$13K |
| D2332 |
|
44 |
24 |
$4K |
| D2331 |
|
43 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$610.86 |
| D1999 |
|
42 |
37 |
$0.00 |