| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,431 |
1,703 |
$804K |
| D2929 |
|
1,352 |
343 |
$318K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,383 |
12,953 |
$292K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,880 |
1,107 |
$279K |
| D0120 |
Periodic oral evaluation - established patient |
8,850 |
8,682 |
$264K |
| D1120 |
Prophylaxis - child |
11,061 |
10,717 |
$236K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,141 |
4,869 |
$191K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,889 |
1,011 |
$120K |
| D1351 |
Sealant - per tooth |
5,437 |
1,446 |
$112K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45,599 |
11,302 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
12,633 |
12,156 |
$96K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,872 |
982 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,329 |
780 |
$73K |
| D0330 |
Panoramic radiographic image |
2,628 |
2,542 |
$66K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,052 |
2,699 |
$63K |
| D0140 |
Limited oral evaluation - problem focused |
1,942 |
1,886 |
$43K |
| D9248 |
|
575 |
557 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,765 |
2,640 |
$24K |
| D1110 |
Prophylaxis - adult |
314 |
303 |
$13K |
| D2920 |
|
218 |
186 |
$5K |
| D9630 |
|
55 |
54 |
$2K |
| D2331 |
|
18 |
13 |
$840.42 |
| D1330 |
|
308 |
295 |
$0.00 |