| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,912 |
1,868 |
$652K |
| D1120 |
Prophylaxis - child |
11,056 |
10,981 |
$400K |
| D1351 |
Sealant - per tooth |
9,141 |
2,215 |
$346K |
| D0120 |
Periodic oral evaluation - established patient |
11,982 |
11,914 |
$304K |
| D1110 |
Prophylaxis - adult |
5,085 |
5,036 |
$253K |
| D9248 |
|
1,754 |
1,721 |
$248K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,666 |
894 |
$216K |
| D0274 |
Bitewings - four radiographic images |
5,391 |
5,317 |
$175K |
| D1206 |
Topical application of fluoride varnish |
6,765 |
6,666 |
$175K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,843 |
4,785 |
$173K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,099 |
4,055 |
$171K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,473 |
898 |
$148K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,190 |
827 |
$124K |
| D0330 |
Panoramic radiographic image |
2,243 |
2,240 |
$117K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,348 |
694 |
$117K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,868 |
8,836 |
$105K |
| D2934 |
|
577 |
268 |
$101K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,684 |
2,611 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
6,236 |
6,124 |
$82K |
| D0272 |
Bitewings - two radiographic images |
2,849 |
2,846 |
$59K |
| D3230 |
|
455 |
206 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
515 |
505 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
505 |
457 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
103 |
96 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$2K |
| D3120 |
|
36 |
25 |
$1K |