| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,569 |
975 |
$441K |
| D1120 |
Prophylaxis - child |
9,583 |
9,583 |
$332K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,311 |
1,064 |
$324K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,509 |
979 |
$259K |
| D0120 |
Periodic oral evaluation - established patient |
8,353 |
8,353 |
$194K |
| D1206 |
Topical application of fluoride varnish |
11,666 |
11,666 |
$190K |
| D0272 |
Bitewings - two radiographic images |
8,033 |
8,033 |
$151K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,487 |
2,487 |
$101K |
| D1110 |
Prophylaxis - adult |
1,938 |
1,938 |
$97K |
| D1351 |
Sealant - per tooth |
3,137 |
991 |
$93K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,283 |
2,209 |
$72K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
824 |
348 |
$64K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
491 |
379 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
488 |
245 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,319 |
3,287 |
$42K |
| D0330 |
Panoramic radiographic image |
680 |
680 |
$34K |
| D9222 |
|
381 |
381 |
$34K |
| D0145 |
Oral evaluation for a patient under three years of age |
809 |
809 |
$30K |
| D9310 |
|
447 |
447 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,272 |
983 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
405 |
405 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
432 |
428 |
$17K |
| D0240 |
|
827 |
804 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
26 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
26 |
$4K |
| D9420 |
|
39 |
39 |
$4K |
| D2330 |
|
25 |
12 |
$2K |
| D1354 |
|
33 |
13 |
$495.00 |