| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,554 |
901 |
$386K |
| D1120 |
Prophylaxis - child |
4,048 |
3,873 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,376 |
628 |
$111K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
509 |
409 |
$105K |
| D0272 |
Bitewings - two radiographic images |
4,446 |
4,061 |
$83K |
| D1206 |
Topical application of fluoride varnish |
4,946 |
4,655 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,593 |
3,434 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,032 |
639 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,098 |
603 |
$67K |
| D0240 |
|
3,140 |
1,509 |
$52K |
| D1351 |
Sealant - per tooth |
1,863 |
443 |
$43K |
| D2390 |
|
284 |
112 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
549 |
241 |
$29K |
| D9222 |
|
323 |
309 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,255 |
1,075 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
718 |
689 |
$19K |
| D9310 |
|
665 |
646 |
$19K |
| D0330 |
Panoramic radiographic image |
459 |
428 |
$16K |
| D1510 |
|
113 |
73 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
489 |
443 |
$13K |
| D9610 |
|
419 |
406 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
529 |
493 |
$5K |
| D2934 |
|
35 |
12 |
$5K |
| D7960 |
|
39 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
161 |
154 |
$4K |
| D1110 |
Prophylaxis - adult |
95 |
92 |
$3K |