| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
849 |
221 |
$100K |
| D1120 |
Prophylaxis - child |
1,544 |
1,487 |
$49K |
| D1351 |
Sealant - per tooth |
1,732 |
335 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,581 |
1,526 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
590 |
264 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,345 |
1,277 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
148 |
$27K |
| D0145 |
Oral evaluation for a patient under three years of age |
194 |
190 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,918 |
1,848 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,135 |
2,005 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,147 |
1,853 |
$21K |
| D1110 |
Prophylaxis - adult |
418 |
403 |
$21K |
| D9248 |
|
180 |
168 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
105 |
$10K |
| D0274 |
Bitewings - four radiographic images |
288 |
280 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
277 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
350 |
329 |
$9K |
| D2934 |
|
52 |
17 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
47 |
27 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
159 |
$3K |
| D1510 |
|
18 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
68 |
66 |
$3K |
| D2330 |
|
24 |
17 |
$2K |
| D0602 |
|
1,808 |
1,743 |
$0.00 |
| D0601 |
|
162 |
158 |
$0.00 |
| D0603 |
|
71 |
69 |
$0.00 |