| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,413 |
463 |
$183K |
| D1351 |
Sealant - per tooth |
2,926 |
767 |
$76K |
| D1120 |
Prophylaxis - child |
1,671 |
1,638 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,443 |
2,394 |
$48K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
484 |
170 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
2,032 |
1,994 |
$40K |
| D1110 |
Prophylaxis - adult |
883 |
865 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,576 |
1,536 |
$34K |
| D7111 |
|
497 |
258 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,149 |
1,062 |
$30K |
| D0274 |
Bitewings - four radiographic images |
776 |
759 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
534 |
521 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
516 |
509 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
205 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
172 |
102 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,254 |
1,212 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,159 |
1,115 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
81 |
$7K |
| D9920 |
|
239 |
195 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
319 |
301 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
39 |
$3K |
| D0330 |
Panoramic radiographic image |
58 |
54 |
$212.92 |
| D1999 |
|
2,337 |
2,012 |
$0.00 |