| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,372 |
685 |
$237K |
| D1120 |
Prophylaxis - child |
5,058 |
5,041 |
$200K |
| D0120 |
Periodic oral evaluation - established patient |
3,414 |
3,406 |
$94K |
| D1206 |
Topical application of fluoride varnish |
4,951 |
4,935 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,079 |
628 |
$75K |
| D1351 |
Sealant - per tooth |
1,819 |
540 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
815 |
342 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,754 |
1,369 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
976 |
974 |
$36K |
| D0272 |
Bitewings - two radiographic images |
2,159 |
2,150 |
$35K |
| D0603 |
|
4,371 |
4,349 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,015 |
979 |
$27K |
| D0240 |
|
1,594 |
966 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,873 |
1,786 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
283 |
160 |
$19K |
| D2929 |
|
161 |
41 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
297 |
297 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
530 |
529 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
401 |
$13K |
| D1354 |
|
2,330 |
1,004 |
$7K |
| D1510 |
|
55 |
37 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
69 |
$5K |
| D0330 |
Panoramic radiographic image |
447 |
445 |
$5K |
| D9248 |
|
25 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$3K |
| D9310 |
|
28 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$955.55 |
| D0602 |
|
49 |
49 |
$308.00 |
| D1330 |
|
3,236 |
3,226 |
$10.28 |
| D1310 |
|
3,228 |
3,218 |
$10.06 |