| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,276 |
410 |
$179K |
| D9248 |
|
725 |
691 |
$82K |
| D1351 |
Sealant - per tooth |
2,466 |
556 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
260 |
$54K |
| D1120 |
Prophylaxis - child |
882 |
858 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,353 |
1,317 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
609 |
592 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,533 |
1,053 |
$16K |
| D1206 |
Topical application of fluoride varnish |
1,095 |
1,066 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,271 |
1,221 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
815 |
790 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
239 |
120 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
394 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
143 |
68 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
55 |
51 |
$7K |
| D1110 |
Prophylaxis - adult |
37 |
36 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
48 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D1330 |
|
162 |
157 |
$882.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$379.54 |
| D0603 |
|
3,054 |
2,680 |
$0.00 |
| D0602 |
|
179 |
165 |
$0.00 |