| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,331 |
961 |
$397K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,923 |
881 |
$288K |
| D0120 |
Periodic oral evaluation - established patient |
2,953 |
2,926 |
$193K |
| D1120 |
Prophylaxis - child |
4,396 |
4,360 |
$183K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,532 |
871 |
$167K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,436 |
2,429 |
$161K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,605 |
1,062 |
$148K |
| D1310 |
|
2,574 |
2,560 |
$114K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,872 |
6,252 |
$90K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,117 |
2,087 |
$84K |
| D9993 |
|
1,097 |
1,095 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,558 |
3,532 |
$57K |
| D2160 |
|
515 |
213 |
$41K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
600 |
266 |
$40K |
| D0272 |
Bitewings - two radiographic images |
3,135 |
3,115 |
$37K |
| D2335 |
|
288 |
103 |
$34K |
| D1351 |
Sealant - per tooth |
984 |
294 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,715 |
2,647 |
$32K |
| D0603 |
|
2,006 |
1,994 |
$29K |
| D0350 |
|
2,039 |
960 |
$26K |
| D0330 |
Panoramic radiographic image |
741 |
737 |
$22K |
| D1510 |
|
98 |
74 |
$20K |
| D0274 |
Bitewings - four radiographic images |
711 |
704 |
$15K |
| D2330 |
|
183 |
71 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
155 |
85 |
$12K |
| D2933 |
|
109 |
41 |
$11K |
| D1206 |
Topical application of fluoride varnish |
495 |
491 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
58 |
$7K |
| D2332 |
|
48 |
26 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
38 |
$3K |
| D0602 |
|
140 |
140 |
$2K |
| D9248 |
|
49 |
48 |
$2K |
| D9430 |
|
25 |
25 |
$800.00 |
| D0601 |
|
32 |
32 |
$480.00 |