| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,575 |
1,148 |
$703K |
| D1120 |
Prophylaxis - child |
6,903 |
6,798 |
$243K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,765 |
711 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
8,769 |
8,666 |
$219K |
| D1206 |
Topical application of fluoride varnish |
9,130 |
9,001 |
$189K |
| D1110 |
Prophylaxis - adult |
2,252 |
2,226 |
$110K |
| D0272 |
Bitewings - two radiographic images |
3,756 |
3,686 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,802 |
1,762 |
$70K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
158 |
148 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
518 |
284 |
$50K |
| D1351 |
Sealant - per tooth |
1,363 |
373 |
$47K |
| D2933 |
|
162 |
39 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
776 |
735 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
242 |
107 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
91 |
$17K |
| D9222 |
|
144 |
135 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,104 |
1,086 |
$14K |
| D0240 |
|
213 |
206 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
124 |
123 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
43 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
134 |
$2K |
| D0274 |
Bitewings - four radiographic images |
70 |
66 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$597.36 |