| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,480 |
669 |
$365K |
| D1120 |
Prophylaxis - child |
4,632 |
4,507 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,151 |
602 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
4,274 |
4,167 |
$66K |
| D1206 |
Topical application of fluoride varnish |
4,699 |
4,575 |
$58K |
| D9420 |
|
269 |
262 |
$55K |
| D1351 |
Sealant - per tooth |
2,379 |
831 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,210 |
1,153 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
732 |
466 |
$38K |
| D9248 |
|
392 |
368 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
660 |
373 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,285 |
2,218 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
878 |
841 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
360 |
350 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
570 |
$12K |
| D0240 |
|
857 |
808 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
460 |
433 |
$4K |
| D1110 |
Prophylaxis - adult |
132 |
126 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$2K |
| D2330 |
|
22 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
114 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$98.80 |
| D1354 |
|
26 |
25 |
$0.00 |