| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,536 |
1,269 |
$712K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,072 |
3,290 |
$600K |
| D1120 |
Prophylaxis - child |
25,498 |
20,122 |
$585K |
| D1206 |
Topical application of fluoride varnish |
17,712 |
14,662 |
$362K |
| D0120 |
Periodic oral evaluation - established patient |
14,611 |
13,058 |
$358K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,484 |
6,953 |
$257K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,933 |
1,959 |
$229K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,976 |
1,328 |
$196K |
| D0272 |
Bitewings - two radiographic images |
10,232 |
8,201 |
$166K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,440 |
4,187 |
$144K |
| D0330 |
Panoramic radiographic image |
2,494 |
2,187 |
$117K |
| D0140 |
Limited oral evaluation - problem focused |
2,132 |
1,817 |
$75K |
| D9420 |
|
129 |
112 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,899 |
1,545 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,295 |
1,518 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
54 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
62 |
38 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
382 |
330 |
$4K |
| D1351 |
Sealant - per tooth |
73 |
25 |
$2K |
| D2330 |
|
29 |
12 |
$2K |
| D9310 |
|
36 |
13 |
$805.52 |
| D9999 |
Unspecified adjunctive procedure, by report |
423 |
365 |
$0.00 |