| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,827 |
1,078 |
$535K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,315 |
1,640 |
$518K |
| D1351 |
Sealant - per tooth |
8,799 |
1,641 |
$227K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,241 |
6,878 |
$187K |
| D9248 |
|
1,622 |
1,576 |
$187K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,282 |
673 |
$183K |
| D1120 |
Prophylaxis - child |
5,019 |
4,935 |
$174K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,266 |
1,240 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
5,148 |
5,066 |
$143K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,727 |
6,612 |
$94K |
| D0220 |
Intraoral - periapical first radiographic image |
7,678 |
7,442 |
$87K |
| D1110 |
Prophylaxis - adult |
1,533 |
1,503 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
901 |
415 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,053 |
2,006 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,494 |
1,459 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
857 |
423 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,862 |
1,840 |
$40K |
| D2934 |
|
198 |
64 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
929 |
893 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
977 |
947 |
$17K |
| D1330 |
|
1,587 |
1,500 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$5K |
| D2332 |
|
34 |
24 |
$4K |
| D0330 |
Panoramic radiographic image |
340 |
329 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D0350 |
|
285 |
175 |
$2K |
| D0603 |
|
11,572 |
10,550 |
$0.09 |