| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,810 |
3,854 |
$815K |
| D1120 |
Prophylaxis - child |
18,092 |
18,092 |
$585K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,654 |
4,876 |
$474K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,186 |
2,625 |
$457K |
| D0120 |
Periodic oral evaluation - established patient |
14,051 |
14,051 |
$305K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,742 |
2,579 |
$265K |
| D0272 |
Bitewings - two radiographic images |
15,948 |
15,943 |
$205K |
| D1206 |
Topical application of fluoride varnish |
8,939 |
8,939 |
$203K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
624 |
624 |
$181K |
| D2331 |
|
753 |
739 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,790 |
5,790 |
$131K |
| D0220 |
Intraoral - periapical first radiographic image |
12,464 |
12,443 |
$131K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,328 |
10,328 |
$113K |
| D1351 |
Sealant - per tooth |
1,910 |
1,333 |
$111K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,875 |
1,675 |
$83K |
| D0240 |
|
3,382 |
3,378 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,258 |
11,257 |
$65K |
| D0330 |
Panoramic radiographic image |
1,928 |
1,928 |
$53K |
| D1110 |
Prophylaxis - adult |
845 |
845 |
$35K |
| D9222 |
|
551 |
551 |
$31K |
| D2335 |
|
82 |
81 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
549 |
463 |
$24K |
| D0274 |
Bitewings - four radiographic images |
695 |
695 |
$15K |
| D2332 |
|
26 |
26 |
$5K |
| D9430 |
|
261 |
257 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
284 |
284 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
237 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
98 |
98 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
807 |
769 |
$0.00 |
| D0603 |
|
3,156 |
3,156 |
$0.00 |
| D1330 |
|
3,159 |
3,159 |
$0.00 |