| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,263 |
1,100 |
$384K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,150 |
1,083 |
$307K |
| D1120 |
Prophylaxis - child |
4,774 |
4,738 |
$242K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,341 |
3,308 |
$220K |
| D0120 |
Periodic oral evaluation - established patient |
2,229 |
2,221 |
$165K |
| D1351 |
Sealant - per tooth |
3,059 |
869 |
$115K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,575 |
814 |
$104K |
| D1206 |
Topical application of fluoride varnish |
5,061 |
5,020 |
$103K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,717 |
911 |
$96K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,323 |
2,158 |
$93K |
| D1310 |
|
1,992 |
1,979 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,876 |
4,077 |
$87K |
| D0210 |
Intraoral - complete series of radiographic images |
1,602 |
1,584 |
$75K |
| D1110 |
Prophylaxis - adult |
754 |
746 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
912 |
451 |
$59K |
| D0350 |
|
4,557 |
1,869 |
$46K |
| D1510 |
|
177 |
143 |
$36K |
| D9430 |
|
1,037 |
970 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
578 |
292 |
$31K |
| D0145 |
Oral evaluation for a patient under three years of age |
425 |
425 |
$29K |
| D0603 |
|
1,995 |
1,980 |
$29K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
61 |
42 |
$29K |
| D2160 |
|
339 |
261 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,113 |
2,053 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
213 |
110 |
$25K |
| D2140 |
|
419 |
263 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,833 |
1,821 |
$22K |
| D0274 |
Bitewings - four radiographic images |
696 |
696 |
$15K |
| D1320 |
|
627 |
627 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
369 |
$7K |
| D2335 |
|
51 |
29 |
$6K |
| D2954 |
|
58 |
40 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
30 |
$3K |
| D9993 |
|
17 |
17 |
$0.00 |