| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,037 |
360 |
$138K |
| D0145 |
Oral evaluation for a patient under three years of age |
759 |
755 |
$105K |
| D1120 |
Prophylaxis - child |
2,913 |
2,868 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
3,448 |
3,413 |
$95K |
| D1351 |
Sealant - per tooth |
2,764 |
564 |
$71K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
721 |
252 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
695 |
373 |
$47K |
| D1110 |
Prophylaxis - adult |
850 |
838 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
470 |
283 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,846 |
2,796 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,741 |
1,701 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
3,058 |
2,925 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,647 |
2,452 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
223 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
814 |
788 |
$20K |
| D9248 |
|
171 |
159 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
450 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
943 |
934 |
$13K |
| D0274 |
Bitewings - four radiographic images |
387 |
380 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
299 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
45 |
$3K |
| D0330 |
Panoramic radiographic image |
28 |
25 |
$1K |
| D7111 |
|
18 |
12 |
$194.99 |
| D1999 |
|
1,521 |
1,382 |
$0.00 |
| D0603 |
|
4,975 |
4,903 |
$0.00 |