| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,145 |
282 |
$145K |
| D0145 |
Oral evaluation for a patient under three years of age |
878 |
849 |
$114K |
| D1351 |
Sealant - per tooth |
4,201 |
858 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
767 |
302 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,494 |
2,313 |
$62K |
| D1120 |
Prophylaxis - child |
1,935 |
1,842 |
$60K |
| D9248 |
|
483 |
440 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,237 |
1,156 |
$35K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
422 |
139 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,067 |
1,019 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,825 |
2,493 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,854 |
1,769 |
$24K |
| D0272 |
Bitewings - two radiographic images |
730 |
697 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
329 |
298 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
120 |
54 |
$7K |
| D2934 |
|
43 |
12 |
$5K |
| D0274 |
Bitewings - four radiographic images |
167 |
159 |
$4K |
| D0350 |
|
385 |
336 |
$4K |
| D1110 |
Prophylaxis - adult |
74 |
68 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
235 |
222 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
87 |
80 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
54 |
$955.14 |
| D0603 |
|
3,233 |
3,079 |
$0.00 |