| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,350 |
857 |
$201K |
| D1120 |
Prophylaxis - child |
3,141 |
3,087 |
$123K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,374 |
3,313 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,100 |
832 |
$75K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
835 |
636 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,434 |
2,389 |
$65K |
| D1351 |
Sealant - per tooth |
918 |
426 |
$57K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
759 |
561 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,650 |
1,628 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
302 |
$39K |
| D1354 |
|
781 |
420 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,189 |
1,959 |
$17K |
| D0274 |
Bitewings - four radiographic images |
896 |
876 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,555 |
2,507 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,343 |
1,318 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
205 |
200 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
65 |
$11K |
| D1510 |
|
99 |
91 |
$10K |
| D2140 |
|
226 |
182 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
345 |
$6K |
| D1110 |
Prophylaxis - adult |
146 |
145 |
$6K |
| D4341 |
|
31 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
46 |
$3K |
| D2335 |
|
20 |
20 |
$3K |
| D2940 |
|
165 |
117 |
$2K |
| D3110 |
|
38 |
29 |
$0.00 |