| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
993 |
361 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,371 |
536 |
$105K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,017 |
350 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
747 |
366 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
532 |
246 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,114 |
981 |
$33K |
| D1351 |
Sealant - per tooth |
1,231 |
315 |
$29K |
| D1120 |
Prophylaxis - child |
1,098 |
996 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,100 |
1,315 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,395 |
1,244 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,607 |
1,447 |
$18K |
| D0272 |
Bitewings - two radiographic images |
891 |
806 |
$15K |
| D2934 |
|
67 |
25 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
150 |
$8K |
| D2332 |
|
68 |
41 |
$6K |
| D1110 |
Prophylaxis - adult |
173 |
133 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
125 |
$3K |
| D0274 |
Bitewings - four radiographic images |
138 |
103 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
62 |
53 |
$2K |
| D1510 |
|
14 |
12 |
$2K |
| D2330 |
|
29 |
16 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D9310 |
|
16 |
16 |
$754.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$374.00 |