| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,017 |
211 |
$137K |
| D0145 |
Oral evaluation for a patient under three years of age |
982 |
956 |
$130K |
| D1351 |
Sealant - per tooth |
4,538 |
831 |
$120K |
| D1120 |
Prophylaxis - child |
2,867 |
2,790 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,484 |
2,468 |
$70K |
| D1206 |
Topical application of fluoride varnish |
3,812 |
3,714 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,689 |
2,601 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,594 |
1,493 |
$49K |
| D1110 |
Prophylaxis - adult |
908 |
885 |
$47K |
| D9248 |
|
426 |
390 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
4,512 |
4,323 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,775 |
4,020 |
$37K |
| D0330 |
Panoramic radiographic image |
1,135 |
1,083 |
$28K |
| D0274 |
Bitewings - four radiographic images |
892 |
868 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
184 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
325 |
325 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
77 |
$12K |
| D1330 |
|
598 |
560 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
51 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
239 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
132 |
125 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
29 |
12 |
$2K |
| D1999 |
|
3,670 |
3,506 |
$0.00 |
| D0603 |
|
5,444 |
5,223 |
$0.00 |