| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
753 |
130 |
$110K |
| D1351 |
Sealant - per tooth |
3,910 |
584 |
$103K |
| D0145 |
Oral evaluation for a patient under three years of age |
578 |
576 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
801 |
241 |
$78K |
| D1120 |
Prophylaxis - child |
968 |
949 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,950 |
839 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
811 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
354 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,266 |
1,246 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
967 |
932 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
368 |
363 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
335 |
321 |
$8K |
| D1110 |
Prophylaxis - adult |
147 |
147 |
$8K |
| D0272 |
Bitewings - two radiographic images |
172 |
171 |
$4K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
125 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
26 |
$2K |
| D0603 |
|
1,983 |
1,960 |
$0.00 |