| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,062 |
1,453 |
$594K |
| D1120 |
Prophylaxis - child |
11,052 |
10,922 |
$579K |
| D7140 |
Extraction, erupted tooth or exposed root |
6,265 |
2,470 |
$358K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
11,856 |
11,715 |
$333K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,136 |
2,378 |
$288K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,473 |
2,246 |
$195K |
| D0330 |
Panoramic radiographic image |
3,869 |
3,825 |
$188K |
| D0272 |
Bitewings - two radiographic images |
8,735 |
8,610 |
$164K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,880 |
8,753 |
$132K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,675 |
2,546 |
$100K |
| D1351 |
Sealant - per tooth |
3,508 |
1,331 |
$74K |
| D1206 |
Topical application of fluoride varnish |
3,027 |
3,014 |
$56K |
| D1110 |
Prophylaxis - adult |
809 |
804 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,919 |
1,212 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,088 |
1,086 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,316 |
2,258 |
$25K |
| D2330 |
|
398 |
258 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
660 |
640 |
$22K |
| D9420 |
|
118 |
117 |
$8K |
| D0274 |
Bitewings - four radiographic images |
228 |
227 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
98 |
63 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
52 |
$5K |
| D2932 |
|
30 |
12 |
$3K |
| D2331 |
|
39 |
28 |
$3K |
| D7111 |
|
45 |
25 |
$3K |
| D2332 |
|
17 |
12 |
$1K |
| D1353 |
|
60 |
26 |
$960.00 |
| D9986 |
|
15 |
15 |
$0.00 |