| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,017 |
951 |
$579K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,652 |
1,275 |
$261K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,327 |
605 |
$187K |
| D1351 |
Sealant - per tooth |
5,149 |
1,169 |
$140K |
| D9248 |
|
1,115 |
1,088 |
$132K |
| D1120 |
Prophylaxis - child |
3,366 |
3,325 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
4,249 |
4,188 |
$120K |
| D0272 |
Bitewings - two radiographic images |
4,314 |
4,260 |
$99K |
| D0145 |
Oral evaluation for a patient under three years of age |
577 |
571 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
6,108 |
6,013 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,142 |
5,862 |
$69K |
| D1110 |
Prophylaxis - adult |
1,230 |
1,209 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,548 |
4,482 |
$65K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,087 |
439 |
$64K |
| D2934 |
|
361 |
129 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,247 |
1,228 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,222 |
1,203 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
61 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
162 |
156 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
27 |
$1K |
| D0160 |
|
15 |
15 |
$209.30 |
| D0601 |
|
1,851 |
1,831 |
$0.00 |
| D0602 |
|
2,101 |
2,078 |
$0.00 |
| D0603 |
|
2,190 |
2,166 |
$0.00 |