| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,764 |
953 |
$387K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,696 |
1,654 |
$275K |
| D0120 |
Periodic oral evaluation - established patient |
9,745 |
9,137 |
$239K |
| D1120 |
Prophylaxis - child |
7,878 |
7,444 |
$202K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,519 |
1,571 |
$190K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,593 |
3,895 |
$188K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,721 |
10,033 |
$168K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,864 |
853 |
$110K |
| D1110 |
Prophylaxis - adult |
2,826 |
2,603 |
$102K |
| D1351 |
Sealant - per tooth |
2,627 |
604 |
$63K |
| D0272 |
Bitewings - two radiographic images |
3,217 |
2,990 |
$53K |
| D0330 |
Panoramic radiographic image |
1,121 |
1,009 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
1,399 |
1,252 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,088 |
989 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,375 |
1,250 |
$40K |
| D9420 |
|
231 |
227 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
874 |
790 |
$12K |
| D0240 |
|
435 |
219 |
$7K |
| D2330 |
|
108 |
55 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
26 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
163 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
13 |
$2K |
| D9110 |
|
13 |
13 |
$578.76 |