| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,593 |
856 |
$183K |
| D1120 |
Prophylaxis - child |
5,885 |
5,644 |
$170K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,562 |
8,177 |
$136K |
| D1110 |
Prophylaxis - adult |
3,012 |
2,869 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
6,048 |
5,675 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,103 |
3,070 |
$99K |
| D0272 |
Bitewings - two radiographic images |
4,695 |
4,453 |
$86K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,608 |
3,260 |
$84K |
| D1351 |
Sealant - per tooth |
3,016 |
1,137 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,025 |
731 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,254 |
966 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
988 |
605 |
$54K |
| D0330 |
Panoramic radiographic image |
1,668 |
1,626 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,354 |
3,206 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,190 |
2,720 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
439 |
430 |
$27K |
| D0274 |
Bitewings - four radiographic images |
504 |
500 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
114 |
50 |
$9K |
| D0603 |
|
2,224 |
2,204 |
$7K |
| D1206 |
Topical application of fluoride varnish |
274 |
271 |
$5K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
16 |
16 |
$4K |
| D0601 |
|
1,107 |
1,096 |
$3K |
| D0602 |
|
1,151 |
1,139 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D2140 |
|
30 |
15 |
$660.70 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$461.40 |