| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,577 |
355 |
$267K |
| D1120 |
Prophylaxis - child |
3,167 |
3,094 |
$114K |
| D0603 |
|
3,350 |
3,281 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,917 |
1,894 |
$52K |
| D1206 |
Topical application of fluoride varnish |
3,205 |
3,134 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,432 |
815 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
135 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
718 |
693 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
69 |
$22K |
| D9310 |
|
154 |
149 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,123 |
1,067 |
$17K |
| D1354 |
|
728 |
217 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,130 |
1,098 |
$16K |
| D0240 |
|
870 |
469 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
478 |
462 |
$13K |
| D2933 |
|
74 |
12 |
$13K |
| D1351 |
Sealant - per tooth |
499 |
142 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
453 |
428 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
75 |
33 |
$11K |
| D0330 |
Panoramic radiographic image |
201 |
192 |
$7K |
| D0602 |
|
130 |
128 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$1K |
| D1330 |
|
261 |
246 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
147 |
137 |
$0.00 |
| D1310 |
|
247 |
233 |
$0.00 |