| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,852 |
2,798 |
$856K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
7,225 |
2,896 |
$585K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,056 |
2,761 |
$410K |
| D9248 |
|
5,932 |
5,691 |
$390K |
| D1120 |
Prophylaxis - child |
10,440 |
10,440 |
$365K |
| D0120 |
Periodic oral evaluation - established patient |
12,416 |
12,416 |
$287K |
| D1110 |
Prophylaxis - adult |
5,488 |
5,488 |
$274K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,867 |
7,450 |
$252K |
| D1206 |
Topical application of fluoride varnish |
15,019 |
15,019 |
$247K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,862 |
1,772 |
$244K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,015 |
2,136 |
$242K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,928 |
4,928 |
$200K |
| D1351 |
Sealant - per tooth |
6,074 |
1,619 |
$181K |
| D2934 |
|
1,338 |
540 |
$168K |
| D0274 |
Bitewings - four radiographic images |
5,505 |
5,505 |
$152K |
| D0272 |
Bitewings - two radiographic images |
7,681 |
7,681 |
$146K |
| D0220 |
Intraoral - periapical first radiographic image |
8,655 |
8,546 |
$109K |
| D0330 |
Panoramic radiographic image |
1,623 |
1,623 |
$79K |
| D0140 |
Limited oral evaluation - problem focused |
2,008 |
1,999 |
$75K |
| D1510 |
|
360 |
285 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,148 |
4,936 |
$53K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,036 |
1,036 |
$46K |
| D2330 |
|
573 |
384 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
50 |
$7K |
| D7111 |
|
54 |
50 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$1K |