| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,597 |
990 |
$468K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,907 |
2,802 |
$392K |
| D1351 |
Sealant - per tooth |
13,183 |
3,386 |
$335K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,610 |
2,522 |
$331K |
| D1120 |
Prophylaxis - child |
9,319 |
8,975 |
$322K |
| D0120 |
Periodic oral evaluation - established patient |
10,511 |
10,122 |
$287K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,697 |
1,650 |
$245K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,584 |
12,135 |
$175K |
| D1110 |
Prophylaxis - adult |
2,976 |
2,880 |
$155K |
| D0220 |
Intraoral - periapical first radiographic image |
13,301 |
12,732 |
$154K |
| D0272 |
Bitewings - two radiographic images |
6,630 |
6,348 |
$143K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,077 |
11,760 |
$137K |
| D9248 |
|
1,123 |
1,044 |
$117K |
| D0274 |
Bitewings - four radiographic images |
3,532 |
3,405 |
$113K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,851 |
2,582 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,923 |
1,869 |
$63K |
| D0350 |
|
5,907 |
5,445 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
282 |
138 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$10K |
| D0330 |
Panoramic radiographic image |
436 |
424 |
$8K |
| D0170 |
|
462 |
433 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
231 |
219 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
27 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
26 |
$3K |
| D0270 |
|
225 |
218 |
$1K |
| D1354 |
|
27 |
13 |
$304.50 |
| D3120 |
|
109 |
43 |
$200.69 |
| D0603 |
|
16,060 |
15,548 |
$0.00 |