| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,846 |
1,933 |
$741K |
| D1120 |
Prophylaxis - child |
17,220 |
17,220 |
$603K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,376 |
3,535 |
$557K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,858 |
1,936 |
$477K |
| D0120 |
Periodic oral evaluation - established patient |
15,996 |
15,996 |
$380K |
| D1110 |
Prophylaxis - adult |
7,257 |
7,257 |
$366K |
| D1208 |
Topical application of fluoride, excluding varnish |
18,661 |
18,661 |
$308K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,945 |
6,945 |
$285K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
8,354 |
8,133 |
$271K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,822 |
1,920 |
$269K |
| D0272 |
Bitewings - two radiographic images |
13,659 |
13,659 |
$248K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,539 |
1,787 |
$213K |
| D1351 |
Sealant - per tooth |
6,688 |
2,220 |
$201K |
| D0330 |
Panoramic radiographic image |
4,241 |
4,241 |
$201K |
| D0274 |
Bitewings - four radiographic images |
7,646 |
7,646 |
$199K |
| D0220 |
Intraoral - periapical first radiographic image |
13,231 |
12,933 |
$169K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,303 |
1,057 |
$165K |
| D0140 |
Limited oral evaluation - problem focused |
2,818 |
2,794 |
$108K |
| D1206 |
Topical application of fluoride varnish |
5,829 |
5,829 |
$95K |
| D7111 |
|
1,367 |
1,023 |
$90K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,620 |
5,766 |
$86K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,805 |
1,805 |
$84K |
| D9420 |
|
741 |
741 |
$64K |
| D2330 |
|
746 |
446 |
$50K |
| D2934 |
|
186 |
78 |
$23K |
| D2331 |
|
166 |
115 |
$14K |
| D9310 |
|
150 |
150 |
$9K |
| D1510 |
|
13 |
12 |
$2K |
| D2332 |
|
15 |
12 |
$2K |
| D0240 |
|
51 |
44 |
$929.80 |