| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,864 |
860 |
$500K |
| D1351 |
Sealant - per tooth |
14,292 |
2,287 |
$376K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,187 |
2,156 |
$301K |
| D0120 |
Periodic oral evaluation - established patient |
8,831 |
8,664 |
$245K |
| D1120 |
Prophylaxis - child |
6,953 |
6,825 |
$242K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,453 |
10,792 |
$241K |
| D1110 |
Prophylaxis - adult |
3,167 |
3,111 |
$166K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,289 |
10,094 |
$145K |
| D0220 |
Intraoral - periapical first radiographic image |
11,725 |
11,331 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,314 |
574 |
$119K |
| D0274 |
Bitewings - four radiographic images |
3,675 |
3,600 |
$117K |
| D0272 |
Bitewings - two radiographic images |
3,402 |
3,328 |
$75K |
| D9248 |
|
610 |
580 |
$68K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
891 |
235 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,653 |
1,577 |
$52K |
| D7240 |
Removal of impacted tooth - completely bony |
182 |
65 |
$50K |
| D2934 |
|
210 |
63 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
387 |
191 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
311 |
148 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
219 |
$14K |
| D0330 |
Panoramic radiographic image |
445 |
438 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
607 |
577 |
$10K |
| D9243 |
|
231 |
96 |
$9K |
| D9239 |
|
102 |
96 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
198 |
181 |
$5K |
| D9310 |
|
26 |
24 |
$260.20 |
| D0603 |
|
13,577 |
13,346 |
$0.00 |