| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,176 |
505 |
$603K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,853 |
1,119 |
$451K |
| D1351 |
Sealant - per tooth |
8,825 |
2,131 |
$369K |
| D1120 |
Prophylaxis - child |
7,391 |
7,117 |
$368K |
| D1206 |
Topical application of fluoride varnish |
9,908 |
9,586 |
$303K |
| D0120 |
Periodic oral evaluation - established patient |
7,114 |
6,790 |
$290K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
981 |
621 |
$192K |
| D1110 |
Prophylaxis - adult |
2,662 |
2,610 |
$191K |
| D0272 |
Bitewings - two radiographic images |
5,193 |
5,020 |
$185K |
| D0274 |
Bitewings - four radiographic images |
2,842 |
2,791 |
$148K |
| D0330 |
Panoramic radiographic image |
1,537 |
1,482 |
$129K |
| D7111 |
|
997 |
436 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
632 |
257 |
$115K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,535 |
1,370 |
$114K |
| D0140 |
Limited oral evaluation - problem focused |
1,916 |
1,786 |
$113K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,004 |
1,840 |
$113K |
| D1354 |
|
1,379 |
372 |
$59K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
263 |
130 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,742 |
601 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
1,436 |
1,335 |
$33K |
| D0240 |
|
1,144 |
736 |
$24K |
| D9920 |
|
52 |
47 |
$7K |
| D2332 |
|
21 |
12 |
$5K |
| D2330 |
|
21 |
13 |
$4K |
| D1999 |
|
1,403 |
1,315 |
$0.00 |
| D0601 |
|
2,355 |
2,245 |
$0.00 |
| D0602 |
|
3,919 |
3,778 |
$0.00 |
| D9420 |
|
314 |
303 |
$0.00 |
| D0603 |
|
2,484 |
2,328 |
$0.00 |
| D9995 |
|
97 |
90 |
$0.00 |