| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,438 |
1,574 |
$623K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,830 |
2,809 |
$547K |
| D1351 |
Sealant - per tooth |
17,176 |
4,053 |
$453K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38,670 |
14,495 |
$417K |
| D0120 |
Periodic oral evaluation - established patient |
14,658 |
14,407 |
$407K |
| D1120 |
Prophylaxis - child |
11,608 |
11,414 |
$405K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,517 |
2,484 |
$344K |
| D1110 |
Prophylaxis - adult |
4,366 |
4,294 |
$227K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,696 |
15,439 |
$221K |
| D0220 |
Intraoral - periapical first radiographic image |
15,918 |
15,462 |
$187K |
| D9248 |
|
1,663 |
1,601 |
$183K |
| D0274 |
Bitewings - four radiographic images |
4,295 |
4,237 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,891 |
1,211 |
$136K |
| D0272 |
Bitewings - two radiographic images |
4,385 |
4,308 |
$98K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,054 |
409 |
$85K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,170 |
2,978 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,782 |
1,735 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
803 |
798 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
237 |
156 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
436 |
291 |
$24K |
| D1330 |
|
2,353 |
2,256 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,182 |
1,156 |
$21K |
| D2332 |
|
45 |
30 |
$6K |
| D0330 |
Panoramic radiographic image |
170 |
163 |
$4K |
| D0350 |
|
16 |
15 |
$126.82 |
| D0340 |
|
31 |
30 |
$99.24 |
| D0602 |
|
11,882 |
11,784 |
$0.00 |
| D0603 |
|
6,709 |
6,620 |
$0.00 |
| D0601 |
|
340 |
336 |
$0.00 |
| D0801 |
|
15 |
14 |
$0.00 |
| D8660 |
|
12 |
12 |
$0.00 |