| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15,327 |
2,667 |
$2.16M |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
11,048 |
2,518 |
$877K |
| D2934 |
|
2,523 |
717 |
$359K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,392 |
960 |
$148K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,437 |
685 |
$133K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,295 |
1,003 |
$133K |
| D1351 |
Sealant - per tooth |
4,031 |
1,334 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,061 |
2,998 |
$99K |
| D0145 |
Oral evaluation for a patient under three years of age |
600 |
598 |
$84K |
| D0272 |
Bitewings - two radiographic images |
3,671 |
3,577 |
$80K |
| D1120 |
Prophylaxis - child |
2,128 |
2,090 |
$74K |
| D9420 |
|
1,913 |
1,879 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,151 |
3,408 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,673 |
1,653 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,937 |
3,816 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,769 |
1,648 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,284 |
2,243 |
$32K |
| D0350 |
|
2,629 |
2,514 |
$26K |
| D0160 |
|
1,568 |
1,541 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
1,030 |
1,018 |
$18K |
| D1510 |
|
124 |
85 |
$17K |
| D1330 |
|
942 |
927 |
$10K |
| D0330 |
Panoramic radiographic image |
113 |
108 |
$6K |
| D2330 |
|
36 |
24 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
12 |
$1K |
| D2140 |
|
30 |
12 |
$831.68 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$693.82 |
| D7111 |
|
40 |
24 |
$421.72 |
| D0603 |
|
7,789 |
7,253 |
$0.00 |