| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,995 |
1,328 |
$797K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,004 |
2,973 |
$416K |
| D1120 |
Prophylaxis - child |
10,136 |
9,896 |
$340K |
| D1351 |
Sealant - per tooth |
10,364 |
1,905 |
$265K |
| D0120 |
Periodic oral evaluation - established patient |
9,315 |
9,099 |
$257K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,299 |
8,108 |
$223K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,914 |
1,034 |
$150K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,938 |
10,688 |
$141K |
| D0272 |
Bitewings - two radiographic images |
6,266 |
6,105 |
$140K |
| D0220 |
Intraoral - periapical first radiographic image |
9,896 |
9,477 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
664 |
374 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
740 |
441 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,957 |
1,899 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,402 |
1,359 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
2,470 |
2,324 |
$42K |
| D1110 |
Prophylaxis - adult |
573 |
564 |
$29K |
| D0330 |
Panoramic radiographic image |
466 |
462 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
200 |
98 |
$16K |
| D0274 |
Bitewings - four radiographic images |
427 |
425 |
$14K |
| D7962 |
|
156 |
152 |
$12K |
| D9420 |
|
284 |
281 |
$10K |
| D1354 |
|
796 |
237 |
$8K |
| D0240 |
|
876 |
530 |
$7K |
| D0350 |
|
643 |
392 |
$5K |
| D1330 |
|
448 |
432 |
$4K |
| D7960 |
|
21 |
12 |
$802.64 |
| D7961 |
|
14 |
14 |
$802.64 |
| D0603 |
|
16,600 |
15,976 |
$0.00 |