| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,671 |
704 |
$448K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,591 |
1,992 |
$417K |
| D1120 |
Prophylaxis - child |
8,430 |
8,415 |
$308K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,709 |
1,245 |
$218K |
| D1206 |
Topical application of fluoride varnish |
9,462 |
9,449 |
$216K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,423 |
1,395 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
8,395 |
8,388 |
$212K |
| D1351 |
Sealant - per tooth |
6,791 |
1,660 |
$180K |
| D0220 |
Intraoral - periapical first radiographic image |
6,437 |
6,346 |
$99K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,014 |
5,115 |
$85K |
| D0240 |
|
4,446 |
2,358 |
$82K |
| D9420 |
|
570 |
568 |
$80K |
| D0272 |
Bitewings - two radiographic images |
2,992 |
2,988 |
$63K |
| D1110 |
Prophylaxis - adult |
1,228 |
1,227 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,126 |
1,120 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,173 |
1,169 |
$36K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
316 |
177 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
635 |
629 |
$26K |
| D9248 |
|
228 |
226 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
43 |
$8K |
| D2934 |
|
29 |
12 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
93 |
$6K |
| D1510 |
|
21 |
15 |
$4K |
| D2330 |
|
34 |
26 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,412 |
1,300 |
$0.00 |