| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,255 |
629 |
$255K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,951 |
1,838 |
$254K |
| D0120 |
Periodic oral evaluation - established patient |
8,884 |
8,457 |
$231K |
| D1120 |
Prophylaxis - child |
6,662 |
6,406 |
$219K |
| D1206 |
Topical application of fluoride varnish |
9,501 |
9,086 |
$127K |
| D1110 |
Prophylaxis - adult |
2,837 |
2,531 |
$125K |
| D0274 |
Bitewings - four radiographic images |
4,115 |
3,708 |
$108K |
| D0220 |
Intraoral - periapical first radiographic image |
7,627 |
7,188 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,466 |
6,512 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,143 |
3,014 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
175 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,091 |
1,044 |
$27K |
| D0330 |
Panoramic radiographic image |
601 |
512 |
$17K |
| D1351 |
Sealant - per tooth |
484 |
121 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
343 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
74 |
37 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
37 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
99 |
$2K |
| D0602 |
|
11,118 |
10,798 |
$0.00 |
| D0603 |
|
441 |
421 |
$0.00 |
| D1999 |
|
75 |
74 |
$0.00 |