| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,370 |
1,628 |
$555K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,396 |
3,047 |
$535K |
| D1120 |
Prophylaxis - child |
9,523 |
9,523 |
$329K |
| D1110 |
Prophylaxis - adult |
5,912 |
5,912 |
$290K |
| D0120 |
Periodic oral evaluation - established patient |
12,170 |
12,170 |
$278K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,984 |
1,032 |
$241K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
7,084 |
6,782 |
$227K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,176 |
1,296 |
$216K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,432 |
1,645 |
$200K |
| D1206 |
Topical application of fluoride varnish |
11,849 |
11,849 |
$193K |
| D9248 |
|
2,481 |
2,378 |
$180K |
| D0274 |
Bitewings - four radiographic images |
5,953 |
5,953 |
$160K |
| D0272 |
Bitewings - two radiographic images |
6,560 |
6,559 |
$124K |
| D0330 |
Panoramic radiographic image |
2,239 |
2,239 |
$109K |
| D0220 |
Intraoral - periapical first radiographic image |
7,920 |
7,880 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,411 |
2,411 |
$98K |
| D7240 |
Removal of impacted tooth - completely bony |
337 |
92 |
$90K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,247 |
6,532 |
$89K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
686 |
477 |
$78K |
| D2934 |
|
610 |
208 |
$76K |
| D0140 |
Limited oral evaluation - problem focused |
1,719 |
1,697 |
$64K |
| D1351 |
Sealant - per tooth |
1,819 |
504 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,716 |
2,716 |
$43K |
| D0145 |
Oral evaluation for a patient under three years of age |
689 |
689 |
$32K |
| D9222 |
|
239 |
238 |
$21K |
| D1510 |
|
103 |
85 |
$17K |
| D2330 |
|
120 |
85 |
$12K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
120 |
90 |
$11K |
| D2332 |
|
52 |
36 |
$6K |
| D9310 |
|
56 |
56 |
$3K |