| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
587 |
215 |
$74K |
| D1351 |
Sealant - per tooth |
1,496 |
397 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
242 |
227 |
$31K |
| D1120 |
Prophylaxis - child |
992 |
909 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
375 |
146 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
311 |
224 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
245 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
951 |
862 |
$22K |
| D9248 |
|
173 |
150 |
$16K |
| D0272 |
Bitewings - two radiographic images |
854 |
770 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,148 |
1,042 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,262 |
1,104 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
674 |
599 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
994 |
849 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
296 |
265 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
150 |
89 |
$8K |
| D1110 |
Prophylaxis - adult |
119 |
99 |
$5K |
| D0330 |
Panoramic radiographic image |
88 |
79 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
53 |
$1K |
| D9420 |
|
28 |
27 |
$944.06 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$918.32 |
| D0140 |
Limited oral evaluation - problem focused |
55 |
48 |
$676.08 |
| D0270 |
|
61 |
57 |
$245.00 |
| D7111 |
|
20 |
12 |
$194.99 |
| D0603 |
|
1,488 |
1,373 |
$0.00 |