| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,992 |
561 |
$195K |
| D0220 |
Intraoral - periapical first radiographic image |
2,690 |
2,558 |
$73K |
| D1120 |
Prophylaxis - child |
2,025 |
1,981 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,726 |
1,698 |
$60K |
| D2390 |
|
153 |
62 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
70 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
957 |
500 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
512 |
496 |
$39K |
| D1510 |
|
172 |
97 |
$33K |
| D9420 |
|
706 |
631 |
$29K |
| D0330 |
Panoramic radiographic image |
268 |
257 |
$26K |
| D1351 |
Sealant - per tooth |
1,224 |
420 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,356 |
2,220 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,425 |
556 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
429 |
272 |
$14K |
| D1110 |
Prophylaxis - adult |
180 |
176 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
868 |
395 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
294 |
285 |
$6K |
| D0603 |
|
113 |
109 |
$3K |
| D9310 |
|
364 |
357 |
$3K |
| D2330 |
|
117 |
62 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
615 |
540 |
$3K |
| D2332 |
|
62 |
28 |
$2K |
| D1330 |
|
2,141 |
2,094 |
$418.04 |
| D0999 |
Unspecified diagnostic procedure, by report |
17 |
17 |
$240.00 |
| D1354 |
|
58 |
24 |
$217.20 |
| D0272 |
Bitewings - two radiographic images |
1,354 |
1,340 |
$167.82 |
| D0240 |
|
163 |
151 |
$156.00 |
| D1206 |
Topical application of fluoride varnish |
2,138 |
2,093 |
$155.94 |
| D0601 |
|
91 |
90 |
$152.00 |
| D3120 |
|
36 |
16 |
$100.00 |
| D0274 |
Bitewings - four radiographic images |
129 |
128 |
$86.99 |
| D0602 |
|
12 |
12 |
$0.00 |
| D9986 |
|
15 |
15 |
$0.00 |