| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,748 |
820 |
$370K |
| D1120 |
Prophylaxis - child |
15,110 |
14,795 |
$293K |
| D0120 |
Periodic oral evaluation - established patient |
17,206 |
16,840 |
$286K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,345 |
2,611 |
$226K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,342 |
12,082 |
$179K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,157 |
1,368 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,445 |
2,189 |
$171K |
| D1351 |
Sealant - per tooth |
7,669 |
2,571 |
$162K |
| D0330 |
Panoramic radiographic image |
3,099 |
3,006 |
$137K |
| D1110 |
Prophylaxis - adult |
4,076 |
3,966 |
$131K |
| D0274 |
Bitewings - four radiographic images |
5,307 |
5,177 |
$101K |
| D1206 |
Topical application of fluoride varnish |
5,552 |
5,424 |
$81K |
| D0272 |
Bitewings - two radiographic images |
7,914 |
7,767 |
$77K |
| D0240 |
|
7,968 |
3,202 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,607 |
2,518 |
$66K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,014 |
1,944 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
694 |
507 |
$43K |
| D7230 |
|
227 |
94 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
1,031 |
986 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,220 |
2,129 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
29 |
13 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
114 |
87 |
$455.00 |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
140 |
$120.00 |