| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,900 |
925 |
$359K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,911 |
1,151 |
$228K |
| D1120 |
Prophylaxis - child |
3,649 |
3,611 |
$151K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
937 |
591 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
3,218 |
3,181 |
$105K |
| D1206 |
Topical application of fluoride varnish |
3,833 |
3,797 |
$103K |
| D7140 |
Extraction, erupted tooth or exposed root |
922 |
558 |
$80K |
| D0140 |
Limited oral evaluation - problem focused |
1,200 |
1,178 |
$72K |
| D1351 |
Sealant - per tooth |
2,156 |
702 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,435 |
1,769 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
2,304 |
2,276 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,451 |
1,433 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
438 |
435 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
151 |
$19K |
| D1510 |
|
49 |
38 |
$10K |
| D2332 |
|
81 |
53 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
52 |
$9K |
| D1110 |
Prophylaxis - adult |
160 |
159 |
$7K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$5K |
| D3110 |
|
110 |
86 |
$4K |
| D2330 |
|
19 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,054 |
1,946 |
$0.00 |