| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,806 |
1,531 |
$649K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,237 |
1,304 |
$271K |
| D1120 |
Prophylaxis - child |
6,512 |
6,512 |
$178K |
| D2932 |
|
1,069 |
371 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,727 |
862 |
$143K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,302 |
1,131 |
$140K |
| D3230 |
|
1,153 |
402 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
4,799 |
4,799 |
$92K |
| D1206 |
Topical application of fluoride varnish |
6,631 |
6,630 |
$91K |
| D9248 |
|
688 |
674 |
$87K |
| D1351 |
Sealant - per tooth |
3,583 |
1,050 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,252 |
728 |
$69K |
| D0272 |
Bitewings - two radiographic images |
3,333 |
3,333 |
$55K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,006 |
1,958 |
$50K |
| D9310 |
|
1,078 |
1,078 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,770 |
1,770 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
2,405 |
2,390 |
$33K |
| D0330 |
Panoramic radiographic image |
557 |
557 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
793 |
786 |
$22K |
| D2330 |
|
235 |
151 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,544 |
1,513 |
$11K |
| D1110 |
Prophylaxis - adult |
206 |
206 |
$9K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$366.00 |