| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,962 |
804 |
$367K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,387 |
869 |
$236K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,911 |
668 |
$158K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,928 |
677 |
$132K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,856 |
721 |
$120K |
| D9420 |
|
626 |
613 |
$75K |
| D2332 |
|
671 |
321 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,993 |
1,777 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,030 |
1,024 |
$41K |
| D1510 |
|
333 |
213 |
$40K |
| D2934 |
|
252 |
123 |
$37K |
| D1120 |
Prophylaxis - child |
1,838 |
1,811 |
$37K |
| D0240 |
|
2,009 |
1,589 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
675 |
642 |
$26K |
| D1206 |
Topical application of fluoride varnish |
2,003 |
1,973 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,049 |
2,003 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
911 |
897 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
142 |
97 |
$16K |
| D2331 |
|
124 |
66 |
$11K |
| D2330 |
|
160 |
98 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
153 |
143 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
90 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D1351 |
Sealant - per tooth |
87 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
28 |
$471.62 |