| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,698 |
1,217 |
$364K |
| D1120 |
Prophylaxis - child |
9,901 |
9,545 |
$267K |
| D1351 |
Sealant - per tooth |
10,464 |
2,433 |
$267K |
| D1206 |
Topical application of fluoride varnish |
9,701 |
9,349 |
$178K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,542 |
1,351 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
6,049 |
5,847 |
$146K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,715 |
1,371 |
$129K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,205 |
1,093 |
$127K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,541 |
3,317 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,749 |
2,658 |
$70K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
933 |
518 |
$58K |
| D0603 |
|
4,779 |
4,590 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,706 |
2,619 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
875 |
853 |
$28K |
| D2330 |
|
814 |
375 |
$28K |
| D9420 |
|
204 |
168 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,555 |
1,486 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
3,784 |
3,597 |
$17K |
| D0601 |
|
2,812 |
2,670 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,685 |
3,049 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
587 |
560 |
$11K |
| D9999 |
Unspecified adjunctive procedure, by report |
145 |
112 |
$8K |
| D0330 |
Panoramic radiographic image |
181 |
179 |
$7K |
| D0274 |
Bitewings - four radiographic images |
712 |
669 |
$6K |
| D1354 |
|
585 |
136 |
$5K |
| D0602 |
|
854 |
837 |
$5K |
| D2390 |
|
32 |
12 |
$2K |
| D2332 |
|
24 |
13 |
$928.72 |
| D9310 |
|
31 |
31 |
$604.00 |
| D9430 |
|
105 |
102 |
$450.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$365.50 |
| D1310 |
|
2,958 |
2,741 |
$0.00 |
| D1330 |
|
2,278 |
2,234 |
$0.00 |