| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,593 |
2,240 |
$731K |
| D1120 |
Prophylaxis - child |
18,302 |
18,302 |
$643K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,191 |
3,413 |
$537K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,646 |
2,700 |
$490K |
| D0120 |
Periodic oral evaluation - established patient |
14,066 |
14,066 |
$335K |
| D1206 |
Topical application of fluoride varnish |
18,792 |
18,792 |
$312K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
8,808 |
7,883 |
$284K |
| D0220 |
Intraoral - periapical first radiographic image |
17,020 |
16,814 |
$221K |
| D0272 |
Bitewings - two radiographic images |
10,842 |
10,842 |
$205K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,847 |
4,847 |
$203K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,195 |
1,669 |
$193K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,074 |
12,620 |
$177K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,387 |
692 |
$128K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,113 |
2,113 |
$103K |
| D0140 |
Limited oral evaluation - problem focused |
2,596 |
2,585 |
$100K |
| D9222 |
|
691 |
691 |
$82K |
| D0330 |
Panoramic radiographic image |
1,799 |
1,799 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
616 |
480 |
$76K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
744 |
437 |
$60K |
| D1110 |
Prophylaxis - adult |
859 |
859 |
$40K |
| D1351 |
Sealant - per tooth |
1,130 |
395 |
$33K |
| D1510 |
|
186 |
151 |
$33K |
| D2934 |
|
39 |
12 |
$5K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$3K |
| D2332 |
|
22 |
14 |
$2K |
| D2330 |
|
23 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$701.26 |