| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,057 |
1,396 |
$716K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,552 |
3,538 |
$493K |
| D1120 |
Prophylaxis - child |
9,191 |
9,126 |
$323K |
| D0120 |
Periodic oral evaluation - established patient |
6,992 |
6,926 |
$195K |
| D0272 |
Bitewings - two radiographic images |
7,976 |
7,900 |
$160K |
| D1206 |
Topical application of fluoride varnish |
9,804 |
9,738 |
$138K |
| D1351 |
Sealant - per tooth |
4,816 |
1,199 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,955 |
2,927 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,073 |
543 |
$98K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,216 |
5,666 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
6,797 |
6,679 |
$78K |
| D0330 |
Panoramic radiographic image |
1,334 |
1,324 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,738 |
1,682 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
496 |
266 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
410 |
219 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
574 |
282 |
$32K |
| D1110 |
Prophylaxis - adult |
270 |
268 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
204 |
204 |
$13K |
| D2934 |
|
73 |
25 |
$10K |
| D9420 |
|
281 |
278 |
$10K |
| D0274 |
Bitewings - four radiographic images |
251 |
250 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$2K |
| D0603 |
|
11,740 |
11,668 |
$0.00 |
| D0602 |
|
2,189 |
2,179 |
$0.00 |