| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,767 |
1,442 |
$747K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,035 |
1,781 |
$361K |
| D1120 |
Prophylaxis - child |
6,045 |
5,994 |
$318K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,030 |
1,495 |
$316K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,173 |
1,320 |
$207K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,016 |
2,980 |
$181K |
| D1206 |
Topical application of fluoride varnish |
6,346 |
6,296 |
$173K |
| D1351 |
Sealant - per tooth |
3,493 |
1,235 |
$143K |
| D0140 |
Limited oral evaluation - problem focused |
2,723 |
2,656 |
$123K |
| D0274 |
Bitewings - four radiographic images |
2,594 |
2,552 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
3,599 |
3,580 |
$109K |
| D0272 |
Bitewings - two radiographic images |
2,543 |
2,512 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
3,785 |
3,696 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,554 |
3,173 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,453 |
2,837 |
$52K |
| D1510 |
|
150 |
107 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
328 |
173 |
$32K |
| D0330 |
Panoramic radiographic image |
711 |
671 |
$32K |
| D2332 |
|
90 |
52 |
$14K |
| D2335 |
|
57 |
24 |
$11K |
| D2330 |
|
84 |
46 |
$8K |
| D1110 |
Prophylaxis - adult |
88 |
87 |
$6K |
| D3120 |
|
97 |
46 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
30 |
$899.00 |
| D1354 |
|
37 |
12 |
$555.00 |