| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,904 |
575 |
$430K |
| D1120 |
Prophylaxis - child |
14,795 |
12,963 |
$356K |
| D1206 |
Topical application of fluoride varnish |
10,742 |
9,976 |
$238K |
| D0120 |
Periodic oral evaluation - established patient |
10,210 |
9,383 |
$238K |
| D1351 |
Sealant - per tooth |
6,736 |
963 |
$154K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,851 |
794 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,292 |
686 |
$122K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,370 |
372 |
$109K |
| D0272 |
Bitewings - two radiographic images |
7,004 |
6,115 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,319 |
2,631 |
$103K |
| D0330 |
Panoramic radiographic image |
1,749 |
1,611 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
883 |
452 |
$68K |
| D9420 |
|
225 |
222 |
$56K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,849 |
1,642 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,956 |
2,905 |
$40K |
| D2330 |
|
272 |
87 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,342 |
1,057 |
$14K |
| D9310 |
|
367 |
219 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
118 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
116 |
$5K |
| D0274 |
Bitewings - four radiographic images |
89 |
88 |
$2K |
| D2331 |
|
22 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
65 |
$847.12 |
| D1110 |
Prophylaxis - adult |
67 |
57 |
$794.15 |