| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,091 |
1,205 |
$580K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,421 |
3,250 |
$526K |
| D1120 |
Prophylaxis - child |
15,820 |
15,564 |
$492K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,333 |
1,197 |
$416K |
| D0120 |
Periodic oral evaluation - established patient |
12,428 |
12,337 |
$281K |
| D1206 |
Topical application of fluoride varnish |
14,037 |
13,949 |
$256K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,344 |
1,665 |
$214K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,682 |
2,030 |
$197K |
| D0272 |
Bitewings - two radiographic images |
8,014 |
7,977 |
$164K |
| D0274 |
Bitewings - four radiographic images |
5,740 |
5,569 |
$162K |
| D0220 |
Intraoral - periapical first radiographic image |
13,255 |
13,018 |
$148K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,910 |
4,701 |
$132K |
| D2940 |
|
2,984 |
854 |
$132K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,389 |
3,266 |
$112K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,131 |
11,850 |
$110K |
| D1351 |
Sealant - per tooth |
3,806 |
1,434 |
$88K |
| D0140 |
Limited oral evaluation - problem focused |
2,284 |
2,216 |
$67K |
| D0240 |
|
3,081 |
2,206 |
$48K |
| D1510 |
|
235 |
189 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,779 |
1,623 |
$28K |
| D9920 |
|
290 |
274 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
281 |
198 |
$24K |
| D0330 |
Panoramic radiographic image |
810 |
808 |
$23K |
| D2330 |
|
169 |
95 |
$12K |
| D2929 |
|
108 |
26 |
$12K |
| D9420 |
|
63 |
63 |
$5K |
| D2332 |
|
35 |
24 |
$4K |
| D9248 |
|
26 |
26 |
$613.27 |