| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,054 |
1,799 |
$332K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,156 |
1,621 |
$220K |
| D9243 |
|
2,280 |
1,567 |
$214K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,502 |
1,716 |
$208K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,698 |
1,545 |
$102K |
| D2335 |
|
746 |
417 |
$69K |
| D9239 |
|
1,805 |
1,546 |
$60K |
| D2330 |
|
595 |
381 |
$26K |
| D9310 |
|
1,564 |
1,455 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,770 |
3,531 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
747 |
486 |
$23K |
| D1120 |
Prophylaxis - child |
3,501 |
3,453 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
428 |
311 |
$20K |
| D1206 |
Topical application of fluoride varnish |
3,522 |
3,472 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
2,076 |
2,039 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
4,253 |
3,921 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
700 |
663 |
$9K |
| D9920 |
|
1,256 |
1,107 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,413 |
1,260 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,548 |
1,526 |
$4K |
| D0272 |
Bitewings - two radiographic images |
2,050 |
2,009 |
$3K |
| D0274 |
Bitewings - four radiographic images |
236 |
220 |
$3K |
| D1354 |
|
1,188 |
290 |
$1K |
| D0330 |
Panoramic radiographic image |
678 |
675 |
$610.35 |
| D1351 |
Sealant - per tooth |
75 |
34 |
$136.01 |
| D0270 |
|
15 |
13 |
$72.80 |
| D0145 |
Oral evaluation for a patient under three years of age |
137 |
137 |
$27.43 |
| D1999 |
|
264 |
176 |
$0.00 |
| D0603 |
|
647 |
630 |
$0.00 |
| D1330 |
|
101 |
100 |
$0.00 |