| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,073 |
798 |
$309K |
| D1351 |
Sealant - per tooth |
6,976 |
1,609 |
$188K |
| D1120 |
Prophylaxis - child |
4,785 |
4,327 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
5,677 |
5,123 |
$121K |
| D1110 |
Prophylaxis - adult |
2,261 |
2,044 |
$102K |
| D0210 |
Intraoral - complete series of radiographic images |
1,309 |
1,229 |
$94K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,904 |
2,445 |
$84K |
| D1206 |
Topical application of fluoride varnish |
3,644 |
3,283 |
$77K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
949 |
574 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,978 |
3,620 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,246 |
2,946 |
$66K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
561 |
271 |
$58K |
| D2140 |
|
944 |
570 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,434 |
1,312 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
587 |
332 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,961 |
1,753 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,394 |
3,051 |
$33K |
| D7240 |
Removal of impacted tooth - completely bony |
103 |
29 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
537 |
324 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,046 |
2,409 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
417 |
372 |
$16K |
| D7111 |
|
226 |
144 |
$15K |
| D2160 |
|
133 |
88 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
108 |
$12K |
| D0330 |
Panoramic radiographic image |
1,679 |
1,525 |
$9K |
| D2330 |
|
60 |
40 |
$4K |
| D9920 |
|
210 |
182 |
$2K |
| D1999 |
|
2,168 |
1,793 |
$15.00 |