| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,374 |
1,081 |
$903K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,036 |
1,015 |
$144K |
| D1351 |
Sealant - per tooth |
4,885 |
1,518 |
$131K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,230 |
506 |
$100K |
| D1120 |
Prophylaxis - child |
2,416 |
2,381 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,926 |
2,864 |
$81K |
| D0272 |
Bitewings - two radiographic images |
3,216 |
3,102 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,281 |
3,194 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,825 |
1,758 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
914 |
416 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
4,002 |
3,745 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,788 |
2,741 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
539 |
283 |
$39K |
| D9420 |
|
876 |
861 |
$31K |
| D0350 |
|
1,927 |
1,800 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
112 |
$19K |
| D0274 |
Bitewings - four radiographic images |
290 |
275 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
309 |
285 |
$8K |
| D0330 |
Panoramic radiographic image |
215 |
215 |
$6K |
| D2934 |
|
25 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$4K |
| D1510 |
|
23 |
17 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
124 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D0270 |
|
26 |
25 |
$112.87 |
| D0603 |
|
5,849 |
5,692 |
$0.00 |