| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,817 |
1,413 |
$553K |
| D1351 |
Sealant - per tooth |
13,578 |
3,451 |
$365K |
| D1120 |
Prophylaxis - child |
7,643 |
7,629 |
$273K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,771 |
1,770 |
$248K |
| D0120 |
Periodic oral evaluation - established patient |
6,769 |
6,760 |
$193K |
| D9248 |
|
1,439 |
1,392 |
$169K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,436 |
1,184 |
$163K |
| D0272 |
Bitewings - two radiographic images |
7,208 |
7,193 |
$148K |
| D1206 |
Topical application of fluoride varnish |
8,920 |
8,903 |
$128K |
| D0350 |
|
10,283 |
9,527 |
$113K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,848 |
2,837 |
$98K |
| D1110 |
Prophylaxis - adult |
1,355 |
1,352 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
662 |
467 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,288 |
4,768 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
5,156 |
5,103 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
790 |
790 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
811 |
448 |
$49K |
| D0330 |
Panoramic radiographic image |
2,093 |
2,088 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,299 |
1,297 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
337 |
216 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
939 |
917 |
$25K |
| D9420 |
|
105 |
103 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
176 |
$3K |
| D2330 |
|
38 |
26 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$264.60 |
| D7111 |
|
12 |
12 |
$114.70 |
| D0603 |
|
11,740 |
11,703 |
$0.00 |