| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,277 |
715 |
$244K |
| D1120 |
Prophylaxis - child |
4,532 |
4,260 |
$195K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,755 |
877 |
$115K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,591 |
811 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
4,189 |
3,943 |
$80K |
| D0272 |
Bitewings - two radiographic images |
4,165 |
3,877 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,191 |
4,870 |
$70K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,425 |
648 |
$62K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
890 |
387 |
$54K |
| D0330 |
Panoramic radiographic image |
918 |
853 |
$34K |
| D1110 |
Prophylaxis - adult |
780 |
711 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
835 |
745 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
779 |
718 |
$18K |
| D9420 |
|
486 |
440 |
$14K |
| D2330 |
|
205 |
110 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
853 |
764 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
779 |
486 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
153 |
143 |
$5K |
| D1351 |
Sealant - per tooth |
139 |
54 |
$2K |
| D2331 |
|
29 |
16 |
$2K |