| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,199 |
488 |
$400K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,643 |
1,613 |
$300K |
| D1110 |
Prophylaxis - adult |
6,108 |
6,100 |
$258K |
| D0120 |
Periodic oral evaluation - established patient |
10,894 |
10,882 |
$248K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,154 |
408 |
$187K |
| D2140 |
|
2,051 |
1,284 |
$184K |
| D1206 |
Topical application of fluoride varnish |
10,360 |
10,345 |
$182K |
| D1120 |
Prophylaxis - child |
5,351 |
5,347 |
$168K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,699 |
7,676 |
$146K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,192 |
668 |
$117K |
| D0274 |
Bitewings - four radiographic images |
3,763 |
3,757 |
$110K |
| D0220 |
Intraoral - periapical first radiographic image |
8,726 |
8,659 |
$108K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,018 |
608 |
$106K |
| D0210 |
Intraoral - complete series of radiographic images |
1,247 |
1,241 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,370 |
1,369 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,309 |
2,305 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
174 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
930 |
918 |
$31K |
| D1351 |
Sealant - per tooth |
828 |
271 |
$28K |
| D9420 |
|
146 |
145 |
$16K |
| D2160 |
|
93 |
57 |
$12K |
| D0330 |
Panoramic radiographic image |
194 |
194 |
$8K |
| D2934 |
|
46 |
12 |
$8K |
| D3120 |
|
103 |
81 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
115 |
$4K |
| D4341 |
|
32 |
13 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
107 |
107 |
$3K |
| D2330 |
|
18 |
12 |
$2K |
| D0180 |
|
30 |
30 |
$1K |