| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,454 |
849 |
$349K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,470 |
1,180 |
$266K |
| D1120 |
Prophylaxis - child |
5,346 |
5,166 |
$145K |
| D1351 |
Sealant - per tooth |
4,273 |
1,179 |
$116K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,540 |
2,414 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,318 |
2,093 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,063 |
3,479 |
$105K |
| D1206 |
Topical application of fluoride varnish |
5,965 |
5,758 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,540 |
3,465 |
$91K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,293 |
622 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
853 |
493 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
4,045 |
3,869 |
$60K |
| D2934 |
|
300 |
66 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
882 |
837 |
$33K |
| D9420 |
|
285 |
266 |
$33K |
| D0330 |
Panoramic radiographic image |
578 |
551 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
333 |
188 |
$27K |
| D1110 |
Prophylaxis - adult |
652 |
628 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,256 |
1,215 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
630 |
599 |
$22K |
| D0274 |
Bitewings - four radiographic images |
297 |
288 |
$9K |
| D0240 |
|
328 |
154 |
$5K |
| D1510 |
|
14 |
12 |
$3K |
| D3120 |
|
15 |
12 |
$0.00 |