| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,010 |
1,960 |
$558K |
| D1120 |
Prophylaxis - child |
20,586 |
19,217 |
$492K |
| D0120 |
Periodic oral evaluation - established patient |
25,976 |
24,355 |
$430K |
| D1351 |
Sealant - per tooth |
22,798 |
4,058 |
$418K |
| D1208 |
Topical application of fluoride, excluding varnish |
24,072 |
22,403 |
$338K |
| D1110 |
Prophylaxis - adult |
6,822 |
6,436 |
$225K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,577 |
1,595 |
$171K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,282 |
1,514 |
$163K |
| D0272 |
Bitewings - two radiographic images |
8,580 |
7,929 |
$137K |
| D2929 |
|
1,025 |
272 |
$116K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,860 |
1,198 |
$91K |
| D0330 |
Panoramic radiographic image |
2,173 |
2,046 |
$90K |
| D0274 |
Bitewings - four radiographic images |
3,710 |
3,469 |
$85K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,662 |
3,225 |
$66K |
| D1206 |
Topical application of fluoride varnish |
4,739 |
4,517 |
$60K |
| D1353 |
|
2,576 |
448 |
$45K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
766 |
420 |
$43K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
664 |
332 |
$40K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,478 |
1,395 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,270 |
1,148 |
$29K |
| D9310 |
|
1,055 |
984 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,726 |
2,504 |
$28K |
| D0240 |
|
1,814 |
1,616 |
$27K |
| D9420 |
|
691 |
652 |
$23K |
| D7111 |
|
265 |
145 |
$11K |
| D1510 |
|
95 |
79 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
683 |
561 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
340 |
310 |
$8K |
| D1354 |
|
784 |
266 |
$5K |
| D1515 |
|
19 |
18 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D0431 |
|
128 |
124 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
171 |
122 |
$2K |
| D2331 |
|
17 |
12 |
$1K |
| D0170 |
|
66 |
59 |
$1K |
| D1555 |
|
18 |
12 |
$397.44 |
| D0602 |
|
20 |
19 |
$70.00 |
| D1999 |
|
96 |
89 |
$0.00 |
| D9985 |
|
51 |
43 |
$0.00 |
| D9920 |
|
64 |
62 |
$0.00 |