| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,837 |
1,390 |
$681K |
| D1351 |
Sealant - per tooth |
18,270 |
3,787 |
$483K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,782 |
2,749 |
$381K |
| D1120 |
Prophylaxis - child |
8,645 |
8,590 |
$299K |
| D0120 |
Periodic oral evaluation - established patient |
9,065 |
9,005 |
$249K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,735 |
1,085 |
$163K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,500 |
8,772 |
$145K |
| D1206 |
Topical application of fluoride varnish |
10,368 |
10,300 |
$144K |
| D0272 |
Bitewings - two radiographic images |
5,559 |
5,507 |
$125K |
| D0210 |
Intraoral - complete series of radiographic images |
1,919 |
1,906 |
$123K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,646 |
1,003 |
$121K |
| D0220 |
Intraoral - periapical first radiographic image |
9,835 |
9,507 |
$115K |
| D1110 |
Prophylaxis - adult |
1,815 |
1,802 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,234 |
683 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,948 |
1,929 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,691 |
1,684 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,064 |
2,000 |
$53K |
| D9248 |
|
456 |
442 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
429 |
224 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
793 |
778 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$176.40 |
| D0603 |
|
14,088 |
13,945 |
$0.00 |