| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,770 |
1,005 |
$416K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,368 |
1,227 |
$370K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,698 |
780 |
$112K |
| D9420 |
|
886 |
858 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
2,978 |
2,973 |
$80K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
914 |
437 |
$77K |
| D1120 |
Prophylaxis - child |
2,428 |
2,425 |
$68K |
| D1351 |
Sealant - per tooth |
2,107 |
729 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
1,553 |
1,542 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
705 |
364 |
$58K |
| D1206 |
Topical application of fluoride varnish |
3,298 |
3,292 |
$55K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,022 |
985 |
$47K |
| D2390 |
|
197 |
75 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,805 |
1,303 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
1,948 |
1,924 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,580 |
1,570 |
$30K |
| D1510 |
|
151 |
85 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
273 |
$13K |
| D2330 |
|
130 |
62 |
$9K |
| D2332 |
|
28 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$743.40 |