| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,611 |
768 |
$356K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,265 |
1,258 |
$175K |
| D1120 |
Prophylaxis - child |
4,867 |
4,826 |
$172K |
| D0120 |
Periodic oral evaluation - established patient |
4,956 |
4,913 |
$138K |
| D1351 |
Sealant - per tooth |
4,502 |
1,204 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,109 |
589 |
$96K |
| D0272 |
Bitewings - two radiographic images |
3,395 |
3,337 |
$76K |
| D1206 |
Topical application of fluoride varnish |
5,079 |
5,036 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
835 |
508 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
4,255 |
4,156 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,917 |
3,618 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,495 |
1,441 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
754 |
744 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
415 |
219 |
$21K |
| D0330 |
Panoramic radiographic image |
362 |
354 |
$20K |
| D1110 |
Prophylaxis - adult |
313 |
309 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
140 |
56 |
$10K |
| D2934 |
|
46 |
12 |
$5K |
| D9248 |
|
41 |
41 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
95 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$796.03 |
| D0602 |
|
1,941 |
1,923 |
$0.00 |
| D0603 |
|
4,840 |
4,808 |
$0.00 |
| D0601 |
|
86 |
86 |
$0.00 |