| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
4,597 |
3,989 |
$614K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,623 |
605 |
$287K |
| D1351 |
Sealant - per tooth |
7,466 |
2,299 |
$206K |
| D1120 |
Prophylaxis - child |
4,854 |
4,845 |
$163K |
| D0120 |
Periodic oral evaluation - established patient |
5,930 |
5,919 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,884 |
838 |
$134K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,752 |
4,740 |
$97K |
| D1110 |
Prophylaxis - adult |
2,252 |
2,244 |
$94K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
557 |
176 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,129 |
458 |
$80K |
| D1206 |
Topical application of fluoride varnish |
3,348 |
3,306 |
$70K |
| D1330 |
|
3,980 |
3,976 |
$52K |
| D1310 |
|
3,942 |
3,938 |
$51K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
593 |
329 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,269 |
1,264 |
$40K |
| D0330 |
Panoramic radiographic image |
780 |
773 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,520 |
1,508 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
252 |
$27K |
| D3240 |
|
122 |
64 |
$25K |
| D9222 |
|
177 |
176 |
$22K |
| D1321 |
|
1,430 |
1,423 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
976 |
970 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
241 |
106 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
200 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
640 |
440 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
866 |
850 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
108 |
$7K |
| D9110 |
|
120 |
119 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
72 |
71 |
$3K |
| D1320 |
|
420 |
418 |
$2K |
| D1999 |
|
13 |
12 |
$70.00 |