| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,882 |
938 |
$674K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,672 |
2,885 |
$608K |
| D0145 |
Oral evaluation for a patient under three years of age |
4,253 |
4,161 |
$572K |
| D1351 |
Sealant - per tooth |
16,215 |
3,195 |
$403K |
| D0120 |
Periodic oral evaluation - established patient |
11,647 |
11,365 |
$308K |
| D1120 |
Prophylaxis - child |
9,055 |
8,854 |
$304K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,840 |
11,074 |
$226K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,063 |
1,324 |
$220K |
| D1110 |
Prophylaxis - adult |
4,373 |
4,249 |
$213K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,734 |
12,461 |
$172K |
| D0274 |
Bitewings - four radiographic images |
5,491 |
5,351 |
$168K |
| D2335 |
|
999 |
335 |
$151K |
| D0220 |
Intraoral - periapical first radiographic image |
12,184 |
11,778 |
$136K |
| D9248 |
|
1,124 |
1,094 |
$127K |
| D0272 |
Bitewings - two radiographic images |
4,640 |
4,535 |
$72K |
| D0330 |
Panoramic radiographic image |
2,047 |
1,997 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,187 |
2,111 |
$67K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
750 |
369 |
$64K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
696 |
206 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,609 |
1,542 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
497 |
492 |
$29K |
| D2332 |
|
234 |
101 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
487 |
209 |
$24K |
| D7240 |
Removal of impacted tooth - completely bony |
45 |
13 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
407 |
396 |
$7K |
| D2330 |
|
29 |
15 |
$2K |
| D0603 |
|
18,185 |
17,778 |
$0.00 |