| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,689 |
830 |
$505K |
| D0120 |
Periodic oral evaluation - established patient |
10,014 |
8,750 |
$259K |
| D1120 |
Prophylaxis - child |
7,038 |
6,113 |
$245K |
| D0272 |
Bitewings - two radiographic images |
8,375 |
7,363 |
$194K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,890 |
8,647 |
$193K |
| D0220 |
Intraoral - periapical first radiographic image |
9,467 |
8,232 |
$166K |
| D1110 |
Prophylaxis - adult |
2,975 |
2,635 |
$140K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,574 |
7,507 |
$119K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,669 |
868 |
$110K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,190 |
483 |
$100K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,998 |
2,600 |
$77K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
850 |
531 |
$67K |
| D1351 |
Sealant - per tooth |
2,520 |
698 |
$65K |
| D2140 |
|
741 |
475 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
1,322 |
1,168 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
477 |
326 |
$37K |
| D0603 |
|
6,603 |
6,101 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
336 |
235 |
$20K |
| D0602 |
|
1,203 |
849 |
$6K |
| D0601 |
|
790 |
548 |
$4K |
| D7111 |
|
44 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$877.80 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$752.40 |