| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,047 |
179 |
$143K |
| D1120 |
Prophylaxis - child |
3,023 |
2,731 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
3,878 |
3,526 |
$100K |
| D0272 |
Bitewings - two radiographic images |
3,671 |
3,288 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,069 |
3,685 |
$77K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
714 |
144 |
$60K |
| D0240 |
|
2,441 |
1,413 |
$57K |
| D1110 |
Prophylaxis - adult |
1,045 |
958 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
699 |
319 |
$45K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
458 |
177 |
$36K |
| D9248 |
|
370 |
306 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,004 |
850 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
732 |
644 |
$23K |
| D1351 |
Sealant - per tooth |
851 |
241 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
253 |
231 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
810 |
639 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
58 |
$10K |
| D2331 |
|
62 |
24 |
$5K |
| D2330 |
|
61 |
16 |
$5K |
| D0330 |
Panoramic radiographic image |
119 |
116 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
42 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$199.50 |