| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,374 |
330 |
$183K |
| D1351 |
Sealant - per tooth |
4,413 |
678 |
$114K |
| D1120 |
Prophylaxis - child |
2,597 |
2,551 |
$87K |
| D0145 |
Oral evaluation for a patient under three years of age |
612 |
607 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,961 |
2,892 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,410 |
3,010 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,455 |
3,372 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,429 |
1,384 |
$43K |
| D1110 |
Prophylaxis - adult |
841 |
815 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
457 |
161 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
3,370 |
3,270 |
$39K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
403 |
124 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
427 |
142 |
$30K |
| D0272 |
Bitewings - two radiographic images |
888 |
876 |
$20K |
| D9248 |
|
255 |
234 |
$18K |
| D0330 |
Panoramic radiographic image |
403 |
390 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
822 |
804 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
239 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
311 |
292 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
30 |
$3K |
| D0603 |
|
667 |
649 |
$0.00 |
| D0602 |
|
863 |
851 |
$0.00 |
| D0601 |
|
3,296 |
3,240 |
$0.00 |