| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,365 |
775 |
$337K |
| D1351 |
Sealant - per tooth |
8,154 |
2,378 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
6,878 |
6,769 |
$192K |
| D1120 |
Prophylaxis - child |
5,422 |
5,345 |
$191K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,912 |
1,086 |
$176K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,191 |
1,290 |
$162K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,142 |
1,131 |
$159K |
| D9248 |
|
975 |
945 |
$113K |
| D1110 |
Prophylaxis - adult |
2,026 |
1,991 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,416 |
7,300 |
$105K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,410 |
3,919 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
4,712 |
4,576 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,475 |
2,433 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
603 |
590 |
$39K |
| D0274 |
Bitewings - four radiographic images |
980 |
962 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
946 |
908 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
1,029 |
1,004 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
224 |
135 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
558 |
539 |
$18K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$8K |
| D0350 |
|
448 |
432 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
50 |
$5K |
| D1354 |
|
244 |
100 |
$3K |
| D9420 |
|
69 |
69 |
$2K |
| D0603 |
|
7,683 |
7,592 |
$0.00 |
| D0602 |
|
965 |
954 |
$0.00 |