| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,583 |
844 |
$374K |
| D0120 |
Periodic oral evaluation - established patient |
14,216 |
13,992 |
$362K |
| D1120 |
Prophylaxis - child |
10,731 |
10,358 |
$295K |
| D1110 |
Prophylaxis - adult |
6,800 |
6,723 |
$259K |
| D1206 |
Topical application of fluoride varnish |
13,364 |
12,972 |
$213K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,469 |
733 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,433 |
831 |
$151K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,461 |
3,256 |
$146K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,499 |
2,402 |
$110K |
| D0274 |
Bitewings - four radiographic images |
3,503 |
3,443 |
$101K |
| D0330 |
Panoramic radiographic image |
2,271 |
2,198 |
$88K |
| D0272 |
Bitewings - two radiographic images |
4,685 |
4,534 |
$79K |
| D0240 |
|
3,159 |
1,510 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
602 |
300 |
$41K |
| D1351 |
Sealant - per tooth |
1,249 |
375 |
$33K |
| D0160 |
|
525 |
455 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,715 |
1,703 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
776 |
760 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,195 |
1,123 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
167 |
98 |
$15K |
| D9610 |
|
324 |
309 |
$12K |
| D9248 |
|
642 |
597 |
$9K |
| D2140 |
|
86 |
53 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
12 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
14 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
65 |
$2K |
| D2160 |
|
17 |
12 |
$2K |
| D9222 |
|
13 |
13 |
$863.68 |
| D1354 |
|
221 |
25 |
$731.10 |