| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,991 |
2,152 |
$952K |
| D0120 |
Periodic oral evaluation - established patient |
7,720 |
7,683 |
$453K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,326 |
1,618 |
$423K |
| D1120 |
Prophylaxis - child |
10,190 |
10,130 |
$403K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,569 |
2,245 |
$373K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,675 |
8,259 |
$224K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,432 |
4,164 |
$201K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,675 |
1,455 |
$170K |
| D1351 |
Sealant - per tooth |
5,339 |
1,557 |
$167K |
| D1206 |
Topical application of fluoride varnish |
10,336 |
10,278 |
$156K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,379 |
2,369 |
$153K |
| D9310 |
|
1,977 |
1,963 |
$98K |
| D0220 |
Intraoral - periapical first radiographic image |
5,200 |
5,119 |
$69K |
| D1510 |
|
247 |
177 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
721 |
504 |
$46K |
| D0272 |
Bitewings - two radiographic images |
3,730 |
3,712 |
$44K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
62 |
41 |
$39K |
| D0145 |
Oral evaluation for a patient under three years of age |
349 |
348 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,026 |
1,020 |
$22K |
| D2330 |
|
249 |
145 |
$20K |
| D9222 |
|
29 |
29 |
$5K |
| D0330 |
Panoramic radiographic image |
152 |
152 |
$4K |
| D0350 |
|
694 |
452 |
$4K |
| D9420 |
|
44 |
36 |
$3K |
| D2332 |
|
21 |
13 |
$2K |
| D9430 |
|
54 |
53 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$384.00 |