| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,218 |
1,094 |
$592K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,293 |
3,217 |
$452K |
| D1120 |
Prophylaxis - child |
9,939 |
9,868 |
$348K |
| D0120 |
Periodic oral evaluation - established patient |
11,386 |
11,323 |
$317K |
| D1351 |
Sealant - per tooth |
9,560 |
2,872 |
$258K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,600 |
1,561 |
$256K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,641 |
1,484 |
$196K |
| D0272 |
Bitewings - two radiographic images |
7,728 |
7,655 |
$160K |
| D1110 |
Prophylaxis - adult |
3,002 |
2,991 |
$157K |
| D0220 |
Intraoral - periapical first radiographic image |
13,626 |
13,385 |
$138K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,439 |
12,435 |
$137K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,851 |
8,798 |
$125K |
| D0274 |
Bitewings - four radiographic images |
3,539 |
3,521 |
$104K |
| D9248 |
|
775 |
753 |
$88K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,250 |
2,994 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,102 |
2,078 |
$70K |
| D0330 |
Panoramic radiographic image |
2,095 |
2,066 |
$59K |
| D1206 |
Topical application of fluoride varnish |
4,006 |
3,981 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
786 |
785 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
415 |
298 |
$41K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
305 |
117 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
968 |
946 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
53 |
$5K |
| D7111 |
|
135 |
89 |
$1K |
| D0270 |
|
117 |
111 |
$488.53 |
| D0350 |
|
46 |
46 |
$215.04 |
| D0603 |
|
16,842 |
16,697 |
$0.00 |
| D3120 |
|
29 |
24 |
$0.00 |