| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,700 |
1,357 |
$778K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,748 |
3,656 |
$514K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,294 |
2,251 |
$490K |
| D1120 |
Prophylaxis - child |
10,453 |
10,152 |
$353K |
| D1351 |
Sealant - per tooth |
12,794 |
2,722 |
$336K |
| D0120 |
Periodic oral evaluation - established patient |
9,056 |
8,801 |
$244K |
| D0272 |
Bitewings - two radiographic images |
9,770 |
9,508 |
$199K |
| D0220 |
Intraoral - periapical first radiographic image |
13,100 |
12,615 |
$130K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,451 |
11,631 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,548 |
808 |
$110K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,412 |
471 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,333 |
3,201 |
$104K |
| D1206 |
Topical application of fluoride varnish |
7,417 |
7,209 |
$100K |
| D9248 |
|
703 |
663 |
$80K |
| D1110 |
Prophylaxis - adult |
1,453 |
1,406 |
$70K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,499 |
2,359 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,189 |
4,055 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,554 |
1,505 |
$44K |
| D0330 |
Panoramic radiographic image |
1,706 |
1,634 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
402 |
402 |
$27K |
| D2933 |
|
169 |
49 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
179 |
124 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
983 |
942 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
218 |
113 |
$10K |
| D1510 |
|
23 |
13 |
$2K |
| D1330 |
|
14 |
12 |
$110.25 |
| D0601 |
|
25 |
25 |
$0.00 |
| D0603 |
|
15,824 |
15,332 |
$0.00 |
| D0602 |
|
1,596 |
1,537 |
$0.00 |