| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,373 |
681 |
$283K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,143 |
1,475 |
$249K |
| D1120 |
Prophylaxis - child |
6,546 |
6,344 |
$203K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,569 |
656 |
$157K |
| D1351 |
Sealant - per tooth |
5,175 |
1,156 |
$138K |
| D1206 |
Topical application of fluoride varnish |
7,505 |
7,266 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
5,406 |
5,290 |
$125K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,394 |
645 |
$120K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,637 |
873 |
$120K |
| D9420 |
|
1,028 |
994 |
$99K |
| D0272 |
Bitewings - two radiographic images |
3,859 |
3,764 |
$84K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,636 |
1,553 |
$58K |
| D0240 |
|
3,198 |
1,766 |
$48K |
| D1110 |
Prophylaxis - adult |
972 |
946 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,251 |
1,218 |
$40K |
| D0330 |
Panoramic radiographic image |
1,152 |
1,129 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,284 |
1,179 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,159 |
1,130 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,587 |
1,546 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
436 |
409 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
147 |
89 |
$12K |
| D2929 |
|
39 |
12 |
$5K |
| D2331 |
|
19 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$1K |
| D2330 |
|
20 |
14 |
$1K |