| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,765 |
1,156 |
$377K |
| D1351 |
Sealant - per tooth |
12,938 |
2,385 |
$339K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,393 |
2,389 |
$333K |
| D1120 |
Prophylaxis - child |
7,403 |
7,361 |
$251K |
| D0120 |
Periodic oral evaluation - established patient |
8,018 |
7,965 |
$213K |
| D0272 |
Bitewings - two radiographic images |
6,690 |
6,659 |
$125K |
| D1206 |
Topical application of fluoride varnish |
9,235 |
9,180 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,192 |
846 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,476 |
1,023 |
$106K |
| D0220 |
Intraoral - periapical first radiographic image |
8,847 |
8,692 |
$101K |
| D1110 |
Prophylaxis - adult |
1,992 |
1,982 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,875 |
7,904 |
$93K |
| D0330 |
Panoramic radiographic image |
1,577 |
1,573 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,900 |
1,882 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,181 |
2,136 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,615 |
1,609 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
666 |
398 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
534 |
534 |
$34K |
| D0350 |
|
1,655 |
1,601 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
591 |
575 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
60 |
40 |
$5K |
| D1510 |
|
12 |
12 |
$2K |
| D0603 |
|
12,350 |
12,252 |
$0.00 |