| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,614 |
2,734 |
$637K |
| D1120 |
Prophylaxis - child |
13,357 |
13,154 |
$467K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,858 |
3,367 |
$454K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,919 |
2,896 |
$405K |
| D0120 |
Periodic oral evaluation - established patient |
14,419 |
14,187 |
$400K |
| D9248 |
|
3,329 |
3,268 |
$360K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,776 |
14,537 |
$209K |
| D0272 |
Bitewings - two radiographic images |
8,971 |
8,829 |
$204K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,175 |
1,540 |
$155K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,204 |
4,983 |
$130K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,869 |
4,719 |
$130K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,877 |
1,272 |
$105K |
| D0220 |
Intraoral - periapical first radiographic image |
7,714 |
7,421 |
$92K |
| D0210 |
Intraoral - complete series of radiographic images |
1,231 |
1,215 |
$82K |
| D1351 |
Sealant - per tooth |
3,164 |
850 |
$81K |
| D1110 |
Prophylaxis - adult |
1,405 |
1,383 |
$72K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
844 |
485 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,274 |
1,258 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
345 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
563 |
550 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
52 |
$5K |
| D0603 |
|
13,835 |
13,677 |
$0.00 |
| D0602 |
|
4,112 |
4,065 |
$0.00 |