| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,203 |
905 |
$388K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,161 |
1,037 |
$232K |
| D2934 |
|
1,474 |
345 |
$198K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,444 |
662 |
$190K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,196 |
529 |
$113K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,853 |
692 |
$109K |
| D2330 |
|
790 |
317 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
602 |
297 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,001 |
990 |
$16K |
| D2331 |
|
180 |
93 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
297 |
297 |
$10K |
| D1120 |
Prophylaxis - child |
329 |
325 |
$9K |
| D1351 |
Sealant - per tooth |
462 |
167 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
654 |
647 |
$7K |
| D1510 |
|
50 |
40 |
$6K |
| D1206 |
Topical application of fluoride varnish |
374 |
372 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
414 |
369 |
$5K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$2K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D2332 |
|
20 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
47 |
$1K |