| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,636 |
839 |
$512K |
| D1351 |
Sealant - per tooth |
9,748 |
1,790 |
$265K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,583 |
1,136 |
$251K |
| D0120 |
Periodic oral evaluation - established patient |
6,233 |
6,141 |
$175K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,199 |
1,169 |
$165K |
| D1120 |
Prophylaxis - child |
4,011 |
3,942 |
$142K |
| D1110 |
Prophylaxis - adult |
2,588 |
2,563 |
$139K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,611 |
6,514 |
$95K |
| D0330 |
Panoramic radiographic image |
1,211 |
1,203 |
$73K |
| D0272 |
Bitewings - two radiographic images |
3,045 |
2,981 |
$69K |
| D0274 |
Bitewings - four radiographic images |
1,951 |
1,928 |
$66K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,503 |
1,346 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,720 |
1,146 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
2,213 |
2,097 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
260 |
106 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
1,126 |
1,087 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
175 |
85 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
190 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
66 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
85 |
$6K |
| D9420 |
|
138 |
135 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
20 |
$3K |
| D0160 |
|
12 |
12 |
$179.40 |
| D0603 |
|
7,038 |
6,927 |
$0.00 |
| D0601 |
|
518 |
516 |
$0.00 |
| D0602 |
|
129 |
127 |
$0.00 |