| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,756 |
312 |
$255K |
| D1351 |
Sealant - per tooth |
5,634 |
1,114 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,306 |
478 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
2,781 |
2,759 |
$78K |
| D0145 |
Oral evaluation for a patient under three years of age |
558 |
552 |
$78K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
886 |
190 |
$72K |
| D1120 |
Prophylaxis - child |
1,927 |
1,911 |
$68K |
| D1110 |
Prophylaxis - adult |
1,208 |
1,200 |
$64K |
| D9248 |
|
430 |
415 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,872 |
3,422 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,175 |
3,151 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,676 |
3,648 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,878 |
1,865 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,050 |
1,045 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,059 |
1,058 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
214 |
95 |
$17K |
| D9420 |
|
260 |
257 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
111 |
$8K |
| D0330 |
Panoramic radiographic image |
333 |
332 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
160 |
150 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$450.72 |
| D0603 |
|
4,503 |
4,465 |
$0.00 |
| D0602 |
|
19 |
19 |
$0.00 |