| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,478 |
706 |
$299K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,892 |
1,086 |
$235K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,481 |
5,633 |
$209K |
| D1351 |
Sealant - per tooth |
8,830 |
1,689 |
$204K |
| D0120 |
Periodic oral evaluation - established patient |
6,990 |
6,799 |
$190K |
| D1120 |
Prophylaxis - child |
5,606 |
5,430 |
$188K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,290 |
1,256 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,631 |
867 |
$169K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,827 |
432 |
$130K |
| D1110 |
Prophylaxis - adult |
2,137 |
2,058 |
$108K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,955 |
7,676 |
$107K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,883 |
815 |
$85K |
| D9248 |
|
942 |
834 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
6,817 |
6,375 |
$76K |
| D0274 |
Bitewings - four radiographic images |
1,587 |
1,523 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,069 |
1,010 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,442 |
1,401 |
$32K |
| D9420 |
|
884 |
782 |
$32K |
| D0330 |
Panoramic radiographic image |
714 |
691 |
$30K |
| D2330 |
|
454 |
172 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,022 |
978 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,026 |
938 |
$17K |
| D2332 |
|
123 |
60 |
$11K |
| D2335 |
|
63 |
12 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
47 |
$8K |
| D0350 |
|
515 |
320 |
$4K |
| D2331 |
|
34 |
13 |
$2K |
| D1354 |
|
56 |
12 |
$621.28 |
| D7111 |
|
17 |
13 |
$183.52 |
| D0603 |
|
10,247 |
9,910 |
$0.00 |