| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,196 |
802 |
$456K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,169 |
3,130 |
$430K |
| D1351 |
Sealant - per tooth |
15,534 |
3,988 |
$413K |
| D1120 |
Prophylaxis - child |
9,477 |
9,392 |
$338K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,958 |
1,237 |
$289K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,618 |
10,167 |
$260K |
| D0120 |
Periodic oral evaluation - established patient |
9,229 |
9,140 |
$260K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,489 |
12,386 |
$179K |
| D1110 |
Prophylaxis - adult |
2,613 |
2,589 |
$140K |
| D0220 |
Intraoral - periapical first radiographic image |
11,210 |
11,054 |
$136K |
| D0210 |
Intraoral - complete series of radiographic images |
1,909 |
1,896 |
$128K |
| D0274 |
Bitewings - four radiographic images |
3,417 |
3,383 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,047 |
3,014 |
$103K |
| D9248 |
|
666 |
658 |
$75K |
| D0272 |
Bitewings - two radiographic images |
2,876 |
2,849 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
682 |
347 |
$52K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
524 |
173 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,334 |
1,282 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
50 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
170 |
$3K |
| D0603 |
|
16,301 |
16,111 |
$0.00 |