| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,888 |
747 |
$366K |
| D0120 |
Periodic oral evaluation - established patient |
14,527 |
13,946 |
$354K |
| D1120 |
Prophylaxis - child |
10,354 |
9,940 |
$335K |
| D1206 |
Topical application of fluoride varnish |
14,230 |
13,654 |
$254K |
| D0240 |
|
10,244 |
5,005 |
$230K |
| D0272 |
Bitewings - two radiographic images |
10,256 |
9,841 |
$227K |
| D1110 |
Prophylaxis - adult |
4,097 |
3,934 |
$180K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,885 |
943 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,971 |
966 |
$124K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,518 |
3,314 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,068 |
444 |
$63K |
| D9248 |
|
725 |
680 |
$59K |
| D0603 |
|
14,605 |
13,999 |
$54K |
| D0330 |
Panoramic radiographic image |
1,004 |
980 |
$49K |
| D1351 |
Sealant - per tooth |
1,996 |
682 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
2,490 |
2,340 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
995 |
944 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,867 |
1,585 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
191 |
63 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
107 |
65 |
$8K |
| D2160 |
|
95 |
54 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
72 |
$6K |
| D2140 |
|
78 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$3K |
| D1354 |
|
262 |
55 |
$3K |
| D2330 |
|
22 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D9215 |
|
222 |
174 |
$0.00 |
| D0170 |
|
18 |
15 |
$0.00 |