| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17,809 |
4,907 |
$2.49M |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
8,583 |
3,301 |
$807K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
9,046 |
4,194 |
$767K |
| D1120 |
Prophylaxis - child |
17,908 |
17,561 |
$636K |
| D9248 |
|
3,664 |
3,209 |
$409K |
| D0120 |
Periodic oral evaluation - established patient |
12,178 |
11,959 |
$334K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,620 |
1,893 |
$257K |
| D1206 |
Topical application of fluoride varnish |
9,209 |
9,034 |
$233K |
| D0272 |
Bitewings - two radiographic images |
10,715 |
10,466 |
$222K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,461 |
4,310 |
$210K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,861 |
3,812 |
$178K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,916 |
8,734 |
$171K |
| D9420 |
|
1,081 |
994 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
6,515 |
6,176 |
$93K |
| D1351 |
Sealant - per tooth |
2,499 |
783 |
$75K |
| D9920 |
|
1,086 |
956 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,884 |
1,732 |
$65K |
| D0330 |
Panoramic radiographic image |
402 |
396 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
78 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
477 |
$7K |
| D2330 |
|
94 |
40 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
42 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
370 |
360 |
$5K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$576.12 |