| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
7,228 |
2,157 |
$990K |
| D1351 |
Sealant - per tooth |
28,789 |
7,947 |
$763K |
| D0145 |
Oral evaluation for a patient under three years of age |
4,762 |
4,718 |
$640K |
| D1120 |
Prophylaxis - child |
16,691 |
16,512 |
$581K |
| D0120 |
Periodic oral evaluation - established patient |
17,412 |
17,223 |
$477K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,440 |
1,780 |
$413K |
| D9248 |
|
2,333 |
2,207 |
$247K |
| D0272 |
Bitewings - two radiographic images |
11,898 |
11,737 |
$242K |
| D1206 |
Topical application of fluoride varnish |
17,281 |
17,101 |
$242K |
| D0274 |
Bitewings - four radiographic images |
5,730 |
5,679 |
$176K |
| D1110 |
Prophylaxis - adult |
2,612 |
2,583 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,428 |
913 |
$132K |
| D0210 |
Intraoral - complete series of radiographic images |
1,328 |
1,328 |
$86K |
| D0330 |
Panoramic radiographic image |
3,552 |
3,503 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,562 |
1,004 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,316 |
2,285 |
$75K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
754 |
545 |
$65K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
809 |
501 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
5,092 |
4,900 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,446 |
3,285 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
581 |
356 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,109 |
2,126 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
1,595 |
1,555 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,980 |
1,943 |
$26K |
| D2934 |
|
152 |
52 |
$21K |
| D9420 |
|
511 |
502 |
$17K |
| D2394 |
|
151 |
128 |
$13K |
| D7111 |
|
951 |
629 |
$10K |
| D2140 |
|
60 |
41 |
$4K |
| D1999 |
|
2,791 |
2,698 |
$10.00 |
| D0603 |
|
24,792 |
24,500 |
$0.04 |
| D0601 |
|
64 |
64 |
$0.00 |