| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,811 |
903 |
$510K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,196 |
1,713 |
$394K |
| D9248 |
|
1,385 |
1,355 |
$154K |
| D1120 |
Prophylaxis - child |
4,733 |
4,663 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
5,582 |
5,501 |
$153K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,068 |
1,054 |
$147K |
| D1110 |
Prophylaxis - adult |
2,797 |
2,755 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,780 |
838 |
$130K |
| D1351 |
Sealant - per tooth |
4,884 |
1,151 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,552 |
7,466 |
$102K |
| D0272 |
Bitewings - two radiographic images |
4,068 |
3,999 |
$88K |
| D0274 |
Bitewings - four radiographic images |
2,528 |
2,486 |
$81K |
| D0350 |
|
6,655 |
6,430 |
$64K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,043 |
471 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
4,857 |
4,603 |
$55K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,411 |
1,947 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,228 |
1,192 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
442 |
204 |
$34K |
| D2934 |
|
128 |
30 |
$16K |
| D9420 |
|
389 |
365 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
272 |
267 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
286 |
$5K |
| D1330 |
|
7,616 |
7,528 |
$4K |
| D0330 |
Panoramic radiographic image |
100 |
99 |
$4K |
| D1206 |
Topical application of fluoride varnish |
405 |
382 |
$2K |
| D9920 |
|
1,111 |
1,085 |
$2K |
| D0170 |
|
231 |
228 |
$1K |
| D7111 |
|
76 |
42 |
$825.84 |
| D0603 |
|
8,684 |
8,505 |
$0.00 |