| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,166 |
270 |
$181K |
| D1206 |
Topical application of fluoride varnish |
6,294 |
6,204 |
$156K |
| D1120 |
Prophylaxis - child |
3,391 |
3,347 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
3,799 |
3,750 |
$112K |
| D1110 |
Prophylaxis - adult |
1,504 |
1,490 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
387 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,397 |
1,376 |
$74K |
| D7140 |
Extraction, erupted tooth or exposed root |
476 |
155 |
$54K |
| D0330 |
Panoramic radiographic image |
844 |
835 |
$38K |
| D1351 |
Sealant - per tooth |
986 |
205 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,236 |
1,222 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
287 |
143 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,712 |
1,689 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
455 |
442 |
$21K |
| D1330 |
|
2,026 |
1,994 |
$12K |
| D9310 |
|
232 |
225 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
884 |
853 |
$9K |
| D3120 |
|
106 |
25 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
39 |
15 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
103 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
83 |
82 |
$2K |
| D0240 |
|
58 |
58 |
$1K |
| D9420 |
|
55 |
55 |
$825.00 |