| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,325 |
879 |
$604K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,486 |
2,479 |
$351K |
| D1120 |
Prophylaxis - child |
5,221 |
5,181 |
$183K |
| D1351 |
Sealant - per tooth |
5,436 |
1,158 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
4,829 |
4,791 |
$133K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,572 |
4,604 |
$123K |
| D0272 |
Bitewings - two radiographic images |
3,779 |
3,744 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
5,559 |
5,439 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,033 |
490 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,566 |
1,553 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,674 |
3,646 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
224 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,934 |
1,920 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,072 |
1,013 |
$26K |
| D1110 |
Prophylaxis - adult |
411 |
408 |
$22K |
| D0274 |
Bitewings - four radiographic images |
656 |
651 |
$19K |
| D0330 |
Panoramic radiographic image |
547 |
545 |
$16K |
| D9248 |
|
104 |
103 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
161 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
284 |
279 |
$5K |
| D1510 |
|
23 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0350 |
|
19 |
19 |
$165.41 |
| D0603 |
|
8,990 |
8,941 |
$0.00 |