| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,402 |
1,122 |
$497K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,215 |
2,249 |
$297K |
| D1120 |
Prophylaxis - child |
10,877 |
10,120 |
$257K |
| D1206 |
Topical application of fluoride varnish |
11,285 |
10,506 |
$248K |
| D0120 |
Periodic oral evaluation - established patient |
8,311 |
7,741 |
$243K |
| D2929 |
|
739 |
95 |
$188K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,810 |
3,541 |
$150K |
| D9999 |
Unspecified adjunctive procedure, by report |
4,006 |
3,719 |
$125K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,125 |
4,243 |
$115K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,804 |
1,169 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,838 |
926 |
$99K |
| D1351 |
Sealant - per tooth |
4,067 |
1,361 |
$90K |
| D8670 |
Periodic orthodontic treatment visit |
353 |
342 |
$76K |
| D0272 |
Bitewings - two radiographic images |
4,476 |
4,172 |
$43K |
| D2390 |
|
205 |
62 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
408 |
190 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
3,691 |
3,407 |
$29K |
| D0330 |
Panoramic radiographic image |
938 |
892 |
$28K |
| D0160 |
|
569 |
547 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
620 |
579 |
$14K |
| D1999 |
|
1,126 |
840 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,450 |
2,489 |
$10K |
| D1110 |
Prophylaxis - adult |
168 |
168 |
$7K |
| D0274 |
Bitewings - four radiographic images |
359 |
326 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$739.70 |