| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
425 |
99 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
362 |
354 |
$50K |
| D1120 |
Prophylaxis - child |
1,420 |
1,391 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,712 |
1,682 |
$46K |
| D1351 |
Sealant - per tooth |
1,715 |
243 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
458 |
170 |
$36K |
| D0240 |
|
2,946 |
1,447 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,859 |
1,820 |
$25K |
| D1110 |
Prophylaxis - adult |
493 |
482 |
$24K |
| D0272 |
Bitewings - two radiographic images |
844 |
826 |
$18K |
| D0274 |
Bitewings - four radiographic images |
527 |
515 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
238 |
227 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
198 |
80 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
123 |
42 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
369 |
343 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
762 |
308 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
243 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
470 |
450 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
36 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
221 |
210 |
$4K |
| D9420 |
|
86 |
82 |
$3K |
| D0603 |
|
2,307 |
2,272 |
$0.00 |