| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,580 |
942 |
$462K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,865 |
1,800 |
$361K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,301 |
2,250 |
$308K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,924 |
6,273 |
$217K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,794 |
1,437 |
$202K |
| D1351 |
Sealant - per tooth |
6,739 |
1,629 |
$179K |
| D1120 |
Prophylaxis - child |
5,197 |
5,044 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
5,492 |
5,338 |
$149K |
| D1206 |
Topical application of fluoride varnish |
6,265 |
6,088 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
6,902 |
6,610 |
$77K |
| D9248 |
|
636 |
612 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,814 |
2,685 |
$70K |
| D1110 |
Prophylaxis - adult |
1,367 |
1,329 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,361 |
2,285 |
$68K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
731 |
296 |
$55K |
| D0350 |
|
2,398 |
2,282 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
884 |
435 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,010 |
980 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,496 |
1,448 |
$32K |
| D2330 |
|
310 |
79 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
99 |
$14K |
| D0330 |
Panoramic radiographic image |
492 |
480 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
458 |
436 |
$7K |
| D1330 |
|
597 |
574 |
$6K |
| D2332 |
|
41 |
26 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
262 |
$4K |
| D2335 |
|
22 |
13 |
$3K |
| D0160 |
|
139 |
135 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D1999 |
|
14 |
13 |
$0.00 |
| D0603 |
|
9,430 |
9,147 |
$0.00 |
| D0602 |
|
26 |
26 |
$0.00 |