| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,323 |
3,029 |
$712K |
| D1120 |
Prophylaxis - child |
24,450 |
24,450 |
$695K |
| D0120 |
Periodic oral evaluation - established patient |
28,697 |
28,697 |
$568K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,333 |
2,812 |
$458K |
| D9248 |
|
2,783 |
2,774 |
$366K |
| D1110 |
Prophylaxis - adult |
8,184 |
8,184 |
$351K |
| D1351 |
Sealant - per tooth |
13,591 |
3,146 |
$308K |
| D0330 |
Panoramic radiographic image |
6,409 |
6,409 |
$293K |
| D1206 |
Topical application of fluoride varnish |
19,974 |
19,974 |
$293K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,985 |
2,545 |
$251K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,291 |
2,436 |
$241K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,485 |
1,560 |
$220K |
| D0272 |
Bitewings - two radiographic images |
11,607 |
11,607 |
$198K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,197 |
12,197 |
$168K |
| D0274 |
Bitewings - four radiographic images |
4,829 |
4,829 |
$138K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,300 |
4,300 |
$122K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,873 |
3,846 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
6,646 |
6,409 |
$94K |
| D2934 |
|
614 |
220 |
$72K |
| D0140 |
Limited oral evaluation - problem focused |
2,422 |
2,383 |
$67K |
| D7111 |
|
933 |
731 |
$54K |
| D1510 |
|
300 |
283 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,686 |
2,505 |
$33K |
| D0240 |
|
1,864 |
1,843 |
$32K |
| D0145 |
Oral evaluation for a patient under three years of age |
768 |
768 |
$23K |
| D2330 |
|
265 |
176 |
$15K |
| D0350 |
|
398 |
397 |
$11K |
| D0601 |
|
83 |
83 |
$759.45 |
| D0603 |
|
24 |
24 |
$219.60 |
| D0602 |
|
22 |
22 |
$201.30 |