| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,174 |
704 |
$461K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,328 |
1,665 |
$357K |
| D0120 |
Periodic oral evaluation - established patient |
13,777 |
13,239 |
$355K |
| D1120 |
Prophylaxis - child |
9,019 |
8,623 |
$238K |
| D1206 |
Topical application of fluoride varnish |
14,661 |
14,058 |
$221K |
| D1110 |
Prophylaxis - adult |
5,297 |
5,137 |
$202K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,359 |
946 |
$152K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,169 |
2,996 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,493 |
799 |
$118K |
| D0272 |
Bitewings - two radiographic images |
4,576 |
4,396 |
$82K |
| D1351 |
Sealant - per tooth |
2,809 |
879 |
$74K |
| D9420 |
|
550 |
530 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
775 |
754 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,285 |
2,169 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,357 |
845 |
$26K |
| D0274 |
Bitewings - four radiographic images |
767 |
743 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
579 |
566 |
$22K |
| D0330 |
Panoramic radiographic image |
178 |
177 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
97 |
42 |
$8K |
| D1354 |
|
250 |
95 |
$2K |
| D0240 |
|
79 |
58 |
$1K |