| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,070 |
959 |
$514K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,591 |
1,070 |
$269K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,108 |
767 |
$263K |
| D1120 |
Prophylaxis - child |
4,727 |
4,719 |
$239K |
| D9248 |
|
715 |
710 |
$224K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,979 |
864 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
4,849 |
4,838 |
$176K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,283 |
5,270 |
$163K |
| D1351 |
Sealant - per tooth |
3,065 |
745 |
$131K |
| D2934 |
|
513 |
162 |
$126K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,059 |
605 |
$124K |
| D3230 |
|
470 |
134 |
$117K |
| D3240 |
|
301 |
133 |
$87K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
820 |
807 |
$63K |
| D9110 |
|
941 |
933 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,495 |
1,281 |
$59K |
| D1110 |
Prophylaxis - adult |
876 |
876 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,084 |
1,082 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
409 |
264 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,092 |
1,088 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,706 |
1,660 |
$24K |
| D0330 |
Panoramic radiographic image |
318 |
317 |
$20K |
| D2332 |
|
173 |
90 |
$20K |
| D1206 |
Topical application of fluoride varnish |
342 |
338 |
$11K |
| D1330 |
|
937 |
936 |
$10K |
| D1310 |
|
942 |
941 |
$10K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$5K |
| D2335 |
|
25 |
12 |
$3K |