| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,480 |
656 |
$287K |
| D1120 |
Prophylaxis - child |
4,086 |
4,057 |
$205K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,704 |
924 |
$162K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,683 |
4,649 |
$133K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,206 |
712 |
$104K |
| D1351 |
Sealant - per tooth |
2,659 |
1,013 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,665 |
1,646 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,018 |
2,997 |
$87K |
| D2335 |
|
529 |
225 |
$87K |
| D0272 |
Bitewings - two radiographic images |
2,649 |
2,616 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
3,006 |
2,916 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,651 |
2,324 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
424 |
286 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,633 |
2,283 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
960 |
943 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
333 |
243 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
365 |
211 |
$36K |
| D2160 |
|
333 |
219 |
$33K |
| D0274 |
Bitewings - four radiographic images |
338 |
336 |
$15K |
| D1110 |
Prophylaxis - adult |
137 |
136 |
$9K |
| D3120 |
|
236 |
136 |
$9K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$7K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
89 |
89 |
$2K |
| D9310 |
|
15 |
12 |
$693.00 |
| D8660 |
|
12 |
12 |
$372.00 |
| D0240 |
|
55 |
28 |
$260.00 |