| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,348 |
385 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
4,177 |
4,140 |
$105K |
| D1120 |
Prophylaxis - child |
3,182 |
3,152 |
$104K |
| D1206 |
Topical application of fluoride varnish |
4,002 |
3,972 |
$76K |
| D0272 |
Bitewings - two radiographic images |
2,995 |
2,978 |
$64K |
| D1351 |
Sealant - per tooth |
2,165 |
648 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
615 |
577 |
$48K |
| D1110 |
Prophylaxis - adult |
920 |
914 |
$42K |
| D0240 |
|
1,620 |
849 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,353 |
1,300 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
342 |
194 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
291 |
142 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
138 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
511 |
498 |
$15K |
| D0603 |
|
2,893 |
2,860 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
141 |
65 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
507 |
498 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
50 |
$5K |
| D9248 |
|
44 |
44 |
$4K |
| D2332 |
|
26 |
15 |
$3K |
| D0602 |
|
587 |
586 |
$2K |
| D2140 |
|
40 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
177 |
176 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
43 |
$693.67 |
| D0601 |
|
87 |
87 |
$350.00 |