| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,631 |
549 |
$515K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,292 |
388 |
$103K |
| D0145 |
Oral evaluation for a patient under three years of age |
485 |
478 |
$66K |
| D1120 |
Prophylaxis - child |
1,918 |
1,875 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,887 |
2,685 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,934 |
1,893 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,318 |
2,274 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
774 |
269 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,027 |
2,950 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,231 |
2,183 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
832 |
816 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
217 |
79 |
$22K |
| D9420 |
|
514 |
506 |
$18K |
| D1351 |
Sealant - per tooth |
641 |
146 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
67 |
$16K |
| D0240 |
|
1,776 |
879 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
285 |
278 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
129 |
$3K |
| D1110 |
Prophylaxis - adult |
70 |
69 |
$3K |
| D9248 |
|
13 |
12 |
$975.04 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$829.14 |
| D3120 |
|
385 |
156 |
$458.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
16 |
$406.65 |
| D0603 |
|
3,629 |
3,592 |
$0.00 |