| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,786 |
457 |
$233K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,056 |
1,033 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,415 |
683 |
$135K |
| D1351 |
Sealant - per tooth |
5,035 |
1,010 |
$129K |
| D1120 |
Prophylaxis - child |
2,931 |
2,827 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,457 |
646 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,049 |
2,928 |
$84K |
| D1206 |
Topical application of fluoride varnish |
3,300 |
3,209 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,777 |
1,659 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,128 |
2,053 |
$42K |
| D1110 |
Prophylaxis - adult |
664 |
638 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,338 |
1,267 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
686 |
310 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
782 |
729 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
324 |
324 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,075 |
1,892 |
$22K |
| D0274 |
Bitewings - four radiographic images |
714 |
684 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
250 |
80 |
$18K |
| D0330 |
Panoramic radiographic image |
770 |
750 |
$16K |
| D2330 |
|
94 |
43 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
214 |
206 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
178 |
171 |
$2K |
| D1510 |
|
15 |
12 |
$2K |
| D9420 |
|
42 |
42 |
$1K |
| D1354 |
|
97 |
12 |
$268.34 |
| D1330 |
|
696 |
691 |
$24.50 |
| D0603 |
|
4,279 |
4,084 |
$0.00 |
| D0602 |
|
612 |
586 |
$0.00 |