| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,830 |
1,239 |
$532K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,521 |
3,155 |
$344K |
| D1351 |
Sealant - per tooth |
11,180 |
2,664 |
$298K |
| D1120 |
Prophylaxis - child |
9,824 |
9,398 |
$298K |
| D1110 |
Prophylaxis - adult |
5,280 |
5,088 |
$263K |
| D0120 |
Periodic oral evaluation - established patient |
11,370 |
10,967 |
$259K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,263 |
1,470 |
$235K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,432 |
811 |
$224K |
| D1206 |
Topical application of fluoride varnish |
7,461 |
7,259 |
$163K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,111 |
3,919 |
$131K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,701 |
4,330 |
$128K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,660 |
1,188 |
$123K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,381 |
1,605 |
$118K |
| D0272 |
Bitewings - two radiographic images |
4,338 |
4,159 |
$99K |
| D0330 |
Panoramic radiographic image |
1,524 |
1,441 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
2,612 |
1,999 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,026 |
1,967 |
$74K |
| D1510 |
|
420 |
277 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,791 |
2,996 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,484 |
3,232 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
3,907 |
3,595 |
$41K |
| D2330 |
|
410 |
200 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
913 |
880 |
$29K |
| D2332 |
|
162 |
97 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
27 |
$9K |
| D1354 |
|
48 |
17 |
$5K |
| D0240 |
|
170 |
75 |
$518.00 |
| D9920 |
|
16 |
14 |
$46.75 |