| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,753 |
752 |
$485K |
| D1120 |
Prophylaxis - child |
21,208 |
20,133 |
$483K |
| D0120 |
Periodic oral evaluation - established patient |
21,222 |
20,199 |
$416K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,986 |
2,666 |
$230K |
| D1206 |
Topical application of fluoride varnish |
10,194 |
9,397 |
$209K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,061 |
12,666 |
$186K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,190 |
1,441 |
$140K |
| D1110 |
Prophylaxis - adult |
3,147 |
2,967 |
$115K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,269 |
632 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,139 |
2,940 |
$95K |
| D0272 |
Bitewings - two radiographic images |
7,973 |
7,559 |
$91K |
| D1351 |
Sealant - per tooth |
3,091 |
1,065 |
$74K |
| D1354 |
|
3,792 |
1,686 |
$64K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,443 |
2,007 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,720 |
1,644 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
1,400 |
1,330 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
117 |
42 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,638 |
1,539 |
$10K |
| D2335 |
|
41 |
13 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
78 |
$1K |