| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,626 |
1,692 |
$644K |
| D1120 |
Prophylaxis - child |
11,497 |
11,460 |
$396K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,094 |
2,280 |
$310K |
| D1206 |
Topical application of fluoride varnish |
12,127 |
12,089 |
$262K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,775 |
1,783 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
7,467 |
7,451 |
$189K |
| D1351 |
Sealant - per tooth |
5,202 |
1,821 |
$167K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,858 |
4,840 |
$145K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,733 |
893 |
$145K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,559 |
3,427 |
$105K |
| D0272 |
Bitewings - two radiographic images |
5,635 |
5,602 |
$93K |
| D0220 |
Intraoral - periapical first radiographic image |
5,796 |
5,703 |
$70K |
| D0140 |
Limited oral evaluation - problem focused |
2,514 |
2,468 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,071 |
4,681 |
$56K |
| D9248 |
|
570 |
551 |
$49K |
| D1354 |
|
5,303 |
1,298 |
$47K |
| D1510 |
|
262 |
201 |
$41K |
| D1110 |
Prophylaxis - adult |
827 |
825 |
$36K |
| D2330 |
|
456 |
234 |
$29K |
| D0274 |
Bitewings - four radiographic images |
867 |
866 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
240 |
$22K |
| D0330 |
Panoramic radiographic image |
221 |
220 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
20 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$572.76 |
| D9420 |
|
403 |
399 |
$145.00 |