| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,280 |
614 |
$591K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
506 |
239 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,419 |
1,401 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,736 |
1,695 |
$39K |
| D1110 |
Prophylaxis - adult |
650 |
642 |
$35K |
| D1351 |
Sealant - per tooth |
1,060 |
324 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
468 |
196 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,093 |
2,027 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,252 |
1,879 |
$24K |
| D1120 |
Prophylaxis - child |
623 |
618 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
310 |
154 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
595 |
562 |
$19K |
| D9420 |
|
554 |
527 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,287 |
1,272 |
$19K |
| D9248 |
|
113 |
108 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
646 |
638 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
81 |
79 |
$11K |
| D2140 |
|
173 |
109 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
125 |
70 |
$9K |
| D2934 |
|
68 |
27 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
209 |
201 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
28 |
$4K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$3K |
| D3230 |
|
28 |
12 |
$1K |
| D7111 |
|
22 |
14 |
$240.87 |
| D0603 |
|
2,227 |
2,171 |
$0.00 |