| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
12,483 |
3,124 |
$658K |
| D1120 |
Prophylaxis - child |
33,727 |
32,997 |
$528K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
11,827 |
5,802 |
$397K |
| D0120 |
Periodic oral evaluation - established patient |
33,556 |
32,891 |
$337K |
| D1208 |
Topical application of fluoride, excluding varnish |
40,814 |
39,937 |
$300K |
| D0220 |
Intraoral - periapical first radiographic image |
47,793 |
45,477 |
$251K |
| D7140 |
Extraction, erupted tooth or exposed root |
6,693 |
2,951 |
$238K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,496 |
1,820 |
$228K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49,281 |
42,248 |
$223K |
| D0274 |
Bitewings - four radiographic images |
15,491 |
15,172 |
$178K |
| D0272 |
Bitewings - two radiographic images |
20,927 |
20,400 |
$172K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,318 |
3,597 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
8,539 |
8,336 |
$155K |
| D1110 |
Prophylaxis - adult |
6,576 |
6,441 |
$119K |
| D1351 |
Sealant - per tooth |
11,637 |
3,753 |
$115K |
| D0330 |
Panoramic radiographic image |
6,712 |
6,572 |
$99K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,957 |
7,205 |
$69K |
| D2933 |
|
699 |
217 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
2,593 |
2,516 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
518 |
343 |
$23K |
| D3230 |
|
468 |
160 |
$19K |
| D1206 |
Topical application of fluoride varnish |
2,133 |
1,973 |
$17K |
| D9248 |
|
548 |
504 |
$14K |
| D2330 |
|
288 |
165 |
$9K |
| D2332 |
|
134 |
79 |
$8K |
| D2390 |
|
86 |
24 |
$6K |
| D1510 |
|
84 |
68 |
$6K |
| D1354 |
|
118 |
28 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
68 |
68 |
$851.01 |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$442.75 |
| D3120 |
|
22 |
13 |
$317.62 |
| D1999 |
|
35 |
35 |
$30.00 |
| D0603 |
|
1,856 |
1,809 |
$0.00 |
| D0602 |
|
706 |
690 |
$0.00 |
| D0601 |
|
918 |
909 |
$0.00 |