| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,759 |
941 |
$626K |
| D1120 |
Prophylaxis - child |
5,668 |
5,450 |
$188K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,273 |
1,233 |
$171K |
| D1351 |
Sealant - per tooth |
6,787 |
1,551 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
6,453 |
6,255 |
$169K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,470 |
851 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,045 |
6,797 |
$94K |
| D0272 |
Bitewings - two radiographic images |
4,508 |
4,300 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
749 |
368 |
$67K |
| D1110 |
Prophylaxis - adult |
1,368 |
1,328 |
$67K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,976 |
1,714 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,479 |
1,434 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,673 |
3,434 |
$39K |
| D1352 |
|
1,226 |
295 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,509 |
1,412 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
417 |
404 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
795 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
407 |
185 |
$19K |
| D0330 |
Panoramic radiographic image |
473 |
450 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
389 |
364 |
$6K |
| D0240 |
|
566 |
338 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
30 |
$4K |
| D9420 |
|
73 |
72 |
$2K |
| D7111 |
|
196 |
96 |
$2K |
| D1999 |
|
1,175 |
888 |
$0.00 |
| D0601 |
|
190 |
186 |
$0.00 |
| D0603 |
|
9,178 |
8,460 |
$0.00 |
| D0602 |
|
865 |
824 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
25 |
25 |
$0.00 |