| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,882 |
1,634 |
$685K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,223 |
2,476 |
$428K |
| D0120 |
Periodic oral evaluation - established patient |
8,676 |
8,483 |
$242K |
| D1120 |
Prophylaxis - child |
10,119 |
9,876 |
$237K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,869 |
1,621 |
$204K |
| D1351 |
Sealant - per tooth |
8,210 |
2,236 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,488 |
1,498 |
$140K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,730 |
769 |
$137K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,887 |
2,819 |
$111K |
| D1206 |
Topical application of fluoride varnish |
4,614 |
4,479 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,582 |
5,466 |
$102K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,445 |
3,015 |
$75K |
| D0272 |
Bitewings - two radiographic images |
6,988 |
6,774 |
$66K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,809 |
1,752 |
$56K |
| D0240 |
|
5,379 |
2,661 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
5,403 |
5,192 |
$43K |
| D1110 |
Prophylaxis - adult |
936 |
910 |
$39K |
| D0330 |
Panoramic radiographic image |
965 |
925 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,455 |
1,400 |
$31K |
| D9630 |
|
411 |
406 |
$18K |
| D1999 |
|
1,640 |
1,517 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,787 |
4,158 |
$11K |
| D7240 |
Removal of impacted tooth - completely bony |
46 |
13 |
$7K |
| D2331 |
|
101 |
53 |
$7K |
| D9248 |
|
67 |
66 |
$4K |
| D2330 |
|
73 |
39 |
$3K |
| D9920 |
|
25 |
25 |
$619.69 |