| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,306 |
1,222 |
$769K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,398 |
2,244 |
$434K |
| D1120 |
Prophylaxis - child |
6,352 |
6,297 |
$224K |
| D9248 |
|
1,855 |
1,809 |
$211K |
| D0120 |
Periodic oral evaluation - established patient |
6,666 |
6,609 |
$187K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,172 |
8,355 |
$186K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,301 |
1,295 |
$181K |
| D7240 |
Removal of impacted tooth - completely bony |
516 |
158 |
$145K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,593 |
595 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,082 |
8,016 |
$115K |
| D1351 |
Sealant - per tooth |
4,223 |
1,176 |
$112K |
| D0220 |
Intraoral - periapical first radiographic image |
9,037 |
8,925 |
$107K |
| D0272 |
Bitewings - two radiographic images |
4,337 |
4,298 |
$95K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,171 |
3,102 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
889 |
503 |
$68K |
| D2934 |
|
463 |
175 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
684 |
681 |
$43K |
| D0160 |
|
2,104 |
2,085 |
$30K |
| D1110 |
Prophylaxis - adult |
518 |
511 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
472 |
467 |
$16K |
| D2330 |
|
168 |
75 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
113 |
$11K |
| D0274 |
Bitewings - four radiographic images |
217 |
213 |
$7K |
| D0350 |
|
111 |
109 |
$950.24 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$655.42 |
| D0603 |
|
12,733 |
12,618 |
$0.00 |