| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,674 |
685 |
$332K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
982 |
600 |
$125K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,075 |
582 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,223 |
1,223 |
$76K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
566 |
353 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,230 |
1,230 |
$42K |
| D1354 |
|
1,425 |
367 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
364 |
251 |
$35K |
| D9310 |
|
465 |
464 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,170 |
1,168 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,499 |
1,439 |
$29K |
| D1120 |
Prophylaxis - child |
565 |
565 |
$24K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
225 |
42 |
$23K |
| D9248 |
|
328 |
315 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
419 |
419 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
268 |
266 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,115 |
729 |
$15K |
| D1206 |
Topical application of fluoride varnish |
444 |
444 |
$13K |
| D1352 |
|
148 |
67 |
$8K |
| D1510 |
|
36 |
29 |
$7K |
| D2330 |
|
55 |
29 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
144 |
$4K |
| D9222 |
|
38 |
38 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
17 |
$3K |
| D1351 |
Sealant - per tooth |
83 |
38 |
$3K |
| D0240 |
|
51 |
36 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$924.00 |
| D3120 |
|
34 |
25 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
329 |
315 |
$0.00 |