| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,038 |
777 |
$325K |
| D1120 |
Prophylaxis - child |
6,705 |
6,431 |
$283K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,648 |
1,342 |
$183K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,598 |
5,338 |
$139K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,870 |
829 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,515 |
5,249 |
$77K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,550 |
2,290 |
$76K |
| D0272 |
Bitewings - two radiographic images |
3,296 |
3,130 |
$56K |
| D1351 |
Sealant - per tooth |
2,845 |
884 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,445 |
3,693 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,690 |
1,665 |
$43K |
| D0330 |
Panoramic radiographic image |
1,138 |
1,090 |
$42K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
686 |
319 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
4,529 |
4,296 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
223 |
221 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,774 |
1,746 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
395 |
195 |
$23K |
| D1110 |
Prophylaxis - adult |
476 |
465 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
742 |
704 |
$21K |
| D9420 |
|
255 |
228 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
186 |
146 |
$15K |
| D0274 |
Bitewings - four radiographic images |
278 |
269 |
$8K |
| D2335 |
|
71 |
28 |
$7K |
| D1510 |
|
18 |
12 |
$2K |
| D0602 |
|
1,373 |
1,359 |
$0.00 |
| D0603 |
|
587 |
585 |
$0.00 |