| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,843 |
1,883 |
$960K |
| D1351 |
Sealant - per tooth |
20,453 |
5,338 |
$546K |
| D0120 |
Periodic oral evaluation - established patient |
12,666 |
12,459 |
$354K |
| D1120 |
Prophylaxis - child |
8,614 |
8,488 |
$307K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,078 |
2,051 |
$286K |
| D1110 |
Prophylaxis - adult |
4,432 |
4,370 |
$236K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,208 |
13,009 |
$188K |
| D9248 |
|
1,638 |
1,578 |
$187K |
| D0220 |
Intraoral - periapical first radiographic image |
13,530 |
13,227 |
$164K |
| D0272 |
Bitewings - two radiographic images |
7,073 |
6,984 |
$162K |
| D0274 |
Bitewings - four radiographic images |
3,913 |
3,859 |
$131K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,843 |
1,594 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
902 |
549 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,655 |
1,596 |
$55K |
| D0330 |
Panoramic radiographic image |
794 |
776 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
280 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
682 |
395 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
550 |
527 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
105 |
65 |
$8K |
| D9420 |
|
119 |
118 |
$4K |
| D1510 |
|
31 |
27 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
149 |
142 |
$3K |
| D7111 |
|
56 |
38 |
$424.39 |
| D0602 |
|
10,383 |
10,249 |
$0.00 |
| D0603 |
|
6,208 |
6,108 |
$0.00 |
| D0601 |
|
15 |
15 |
$0.00 |