| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,787 |
1,146 |
$879K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,159 |
2,142 |
$298K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,023 |
8,178 |
$281K |
| D1351 |
Sealant - per tooth |
9,855 |
2,100 |
$256K |
| D1120 |
Prophylaxis - child |
5,842 |
5,771 |
$202K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,164 |
609 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
6,076 |
6,017 |
$168K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,297 |
589 |
$118K |
| D2933 |
|
826 |
189 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,989 |
6,913 |
$98K |
| D0220 |
Intraoral - periapical first radiographic image |
9,007 |
8,793 |
$96K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,461 |
617 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,067 |
2,004 |
$67K |
| D1110 |
Prophylaxis - adult |
1,060 |
1,050 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,985 |
1,958 |
$54K |
| D9248 |
|
433 |
419 |
$50K |
| D0330 |
Panoramic radiographic image |
757 |
740 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,375 |
1,343 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
887 |
850 |
$23K |
| D1330 |
|
2,189 |
2,134 |
$20K |
| D0350 |
|
1,317 |
1,282 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
944 |
920 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
96 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$5K |
| D1510 |
|
26 |
16 |
$4K |
| D2330 |
|
25 |
12 |
$2K |
| D1354 |
|
100 |
16 |
$1K |
| D1206 |
Topical application of fluoride varnish |
18 |
17 |
$205.80 |
| D7111 |
|
14 |
12 |
$149.11 |
| D3120 |
|
59 |
30 |
$57.34 |
| D1999 |
|
9,026 |
8,459 |
$0.00 |
| D0603 |
|
10,675 |
10,558 |
$0.00 |