| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15,849 |
4,907 |
$1.81M |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14,631 |
7,121 |
$857K |
| D0120 |
Periodic oral evaluation - established patient |
38,336 |
35,994 |
$748K |
| D1120 |
Prophylaxis - child |
33,593 |
31,500 |
$744K |
| D1206 |
Topical application of fluoride varnish |
25,591 |
23,631 |
$468K |
| D1351 |
Sealant - per tooth |
16,906 |
6,310 |
$407K |
| D0330 |
Panoramic radiographic image |
7,941 |
7,258 |
$374K |
| D2140 |
|
7,583 |
4,452 |
$351K |
| D2160 |
|
5,016 |
2,978 |
$338K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,058 |
3,374 |
$333K |
| D1208 |
Topical application of fluoride, excluding varnish |
21,732 |
20,446 |
$329K |
| D1110 |
Prophylaxis - adult |
8,336 |
7,834 |
$306K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,636 |
9,556 |
$292K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
10,171 |
8,282 |
$286K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,337 |
2,525 |
$284K |
| D0274 |
Bitewings - four radiographic images |
12,545 |
11,800 |
$263K |
| D0240 |
|
23,504 |
9,338 |
$255K |
| D0272 |
Bitewings - two radiographic images |
23,206 |
21,631 |
$241K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,273 |
2,328 |
$241K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,321 |
1,559 |
$227K |
| D2933 |
|
547 |
214 |
$92K |
| D0140 |
Limited oral evaluation - problem focused |
1,696 |
1,597 |
$42K |
| D1510 |
|
354 |
278 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
951 |
828 |
$31K |
| D2330 |
|
394 |
281 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,341 |
2,076 |
$12K |
| D2161 |
|
102 |
83 |
$8K |
| D1354 |
|
250 |
123 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
86 |
67 |
$5K |
| D2331 |
|
51 |
38 |
$3K |
| D0270 |
|
13 |
13 |
$60.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
15 |
$50.00 |
| D9215 |
|
2,558 |
2,124 |
$0.00 |
| D1330 |
|
1,623 |
1,571 |
$0.00 |