| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,330 |
863 |
$276K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,401 |
1,586 |
$261K |
| D0120 |
Periodic oral evaluation - established patient |
6,375 |
6,240 |
$175K |
| D1120 |
Prophylaxis - child |
6,460 |
6,337 |
$161K |
| D1206 |
Topical application of fluoride varnish |
7,903 |
7,749 |
$111K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,500 |
4,121 |
$102K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,703 |
821 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,266 |
2,233 |
$90K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,193 |
446 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,317 |
759 |
$88K |
| D0330 |
Panoramic radiographic image |
1,538 |
1,506 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
600 |
440 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
4,873 |
4,730 |
$52K |
| D1110 |
Prophylaxis - adult |
1,442 |
1,418 |
$47K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,607 |
1,555 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,876 |
1,851 |
$29K |
| D1351 |
Sealant - per tooth |
1,099 |
387 |
$26K |
| D0274 |
Bitewings - four radiographic images |
729 |
727 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
514 |
501 |
$16K |
| D1510 |
|
93 |
67 |
$12K |
| D2332 |
|
85 |
57 |
$7K |
| D2330 |
|
162 |
105 |
$7K |
| D2934 |
|
39 |
12 |
$4K |