| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,010 |
733 |
$434K |
| D1351 |
Sealant - per tooth |
15,594 |
3,991 |
$434K |
| D0120 |
Periodic oral evaluation - established patient |
9,575 |
9,528 |
$274K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,602 |
1,598 |
$226K |
| D1120 |
Prophylaxis - child |
6,038 |
6,010 |
$219K |
| D1110 |
Prophylaxis - adult |
3,752 |
3,732 |
$203K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,576 |
893 |
$162K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,868 |
8,676 |
$161K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,821 |
9,774 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,795 |
1,035 |
$141K |
| D0272 |
Bitewings - two radiographic images |
5,421 |
5,394 |
$124K |
| D0220 |
Intraoral - periapical first radiographic image |
9,355 |
9,229 |
$114K |
| D0274 |
Bitewings - four radiographic images |
3,295 |
3,276 |
$111K |
| D9248 |
|
681 |
667 |
$80K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,312 |
1,274 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
163 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
13 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
104 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$832.78 |
| D7111 |
|
30 |
25 |
$344.10 |
| D0603 |
|
11,813 |
11,743 |
$0.00 |