| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,748 |
830 |
$438K |
| D1110 |
Prophylaxis - adult |
7,004 |
6,950 |
$350K |
| D0120 |
Periodic oral evaluation - established patient |
11,131 |
11,064 |
$336K |
| D1206 |
Topical application of fluoride varnish |
11,358 |
11,287 |
$274K |
| D0274 |
Bitewings - four radiographic images |
6,052 |
5,996 |
$227K |
| D0330 |
Panoramic radiographic image |
2,637 |
2,618 |
$169K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,243 |
1,249 |
$165K |
| D1120 |
Prophylaxis - child |
5,544 |
5,521 |
$158K |
| D0140 |
Limited oral evaluation - problem focused |
4,151 |
4,014 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,949 |
1,210 |
$134K |
| D1351 |
Sealant - per tooth |
4,962 |
1,339 |
$129K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,901 |
982 |
$93K |
| D0272 |
Bitewings - two radiographic images |
3,720 |
3,699 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,196 |
2,182 |
$69K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
863 |
605 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
4,202 |
4,107 |
$58K |
| D2331 |
|
529 |
334 |
$38K |
| D2330 |
|
636 |
354 |
$37K |
| D0160 |
|
642 |
640 |
$25K |
| D2940 |
|
669 |
496 |
$24K |
| D0145 |
Oral evaluation for a patient under three years of age |
610 |
608 |
$23K |
| D9420 |
|
873 |
869 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,711 |
1,151 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,111 |
1,024 |
$15K |
| D2140 |
|
254 |
195 |
$14K |
| D2332 |
|
149 |
88 |
$10K |
| D1354 |
|
1,371 |
558 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
57 |
26 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D2335 |
|
28 |
26 |
$2K |
| D2160 |
|
13 |
12 |
$1K |
| D4355 |
|
12 |
12 |
$697.92 |
| D1999 |
|
1,598 |
1,380 |
$53.58 |
| D9995 |
|
59 |
56 |
$0.00 |