| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,762 |
552 |
$238K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,513 |
1,502 |
$207K |
| D1351 |
Sealant - per tooth |
4,588 |
1,100 |
$120K |
| D1120 |
Prophylaxis - child |
3,476 |
3,390 |
$115K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,944 |
3,228 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,724 |
2,644 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
595 |
364 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
748 |
399 |
$53K |
| D1206 |
Topical application of fluoride varnish |
3,751 |
3,661 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
3,869 |
3,699 |
$41K |
| D9248 |
|
363 |
357 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,181 |
1,154 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,302 |
1,267 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
305 |
100 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
314 |
167 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
553 |
531 |
$14K |
| D0330 |
Panoramic radiographic image |
241 |
229 |
$7K |
| D2934 |
|
34 |
12 |
$5K |
| D0240 |
|
530 |
265 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
220 |
213 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
63 |
$1K |
| D0603 |
|
5,986 |
5,872 |
$0.00 |