| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,207 |
735 |
$232K |
| D0120 |
Periodic oral evaluation - established patient |
4,730 |
4,569 |
$82K |
| D0274 |
Bitewings - four radiographic images |
1,889 |
1,816 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,913 |
4,716 |
$78K |
| D1120 |
Prophylaxis - child |
4,164 |
4,054 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
561 |
556 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
967 |
566 |
$50K |
| D1351 |
Sealant - per tooth |
3,522 |
862 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,224 |
599 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,373 |
733 |
$31K |
| D1110 |
Prophylaxis - adult |
1,745 |
1,673 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
828 |
808 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,277 |
4,172 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
1,114 |
1,079 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
5,542 |
5,292 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
149 |
146 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
147 |
77 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
708 |
650 |
$7K |
| D1330 |
|
5,724 |
5,540 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$3K |
| D9920 |
|
860 |
665 |
$3K |
| D0330 |
Panoramic radiographic image |
68 |
62 |
$3K |
| D1206 |
Topical application of fluoride varnish |
1,574 |
1,506 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
16 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
27 |
$1K |
| D2330 |
|
41 |
27 |
$847.90 |
| D0601 |
|
1,765 |
1,738 |
$770.00 |
| D0272 |
Bitewings - two radiographic images |
260 |
249 |
$755.99 |
| D0603 |
|
1,481 |
1,436 |
$520.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$400.00 |
| D0602 |
|
209 |
208 |
$155.00 |