| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,855 |
428 |
$239K |
| D1351 |
Sealant - per tooth |
9,660 |
1,315 |
$214K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,175 |
1,142 |
$145K |
| D1120 |
Prophylaxis - child |
3,775 |
3,614 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,034 |
2,915 |
$77K |
| D0272 |
Bitewings - two radiographic images |
3,069 |
2,945 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,603 |
3,440 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,350 |
3,200 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,227 |
3,089 |
$34K |
| D9248 |
|
504 |
471 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
775 |
729 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
462 |
224 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
163 |
65 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
589 |
564 |
$11K |
| D1110 |
Prophylaxis - adult |
125 |
123 |
$6K |
| D1206 |
Topical application of fluoride varnish |
361 |
360 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
16 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
95 |
92 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
86 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D0602 |
|
191 |
191 |
$0.00 |
| D0603 |
|
4,632 |
4,485 |
$0.00 |
| D0601 |
|
194 |
190 |
$0.00 |