| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,605 |
820 |
$428K |
| D0120 |
Periodic oral evaluation - established patient |
11,113 |
10,421 |
$282K |
| D1120 |
Prophylaxis - child |
11,835 |
11,005 |
$258K |
| D1206 |
Topical application of fluoride varnish |
12,107 |
11,264 |
$226K |
| D1351 |
Sealant - per tooth |
6,504 |
1,529 |
$138K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,165 |
1,160 |
$138K |
| D9999 |
Unspecified adjunctive procedure, by report |
3,717 |
3,460 |
$103K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,212 |
713 |
$62K |
| D9920 |
|
2,068 |
1,895 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
998 |
436 |
$52K |
| D0272 |
Bitewings - two radiographic images |
5,103 |
4,717 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,277 |
1,135 |
$47K |
| D0330 |
Panoramic radiographic image |
865 |
805 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
1,519 |
1,386 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
3,440 |
3,104 |
$26K |
| D1110 |
Prophylaxis - adult |
434 |
414 |
$16K |
| D0240 |
|
1,524 |
758 |
$12K |
| D1999 |
|
879 |
696 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
356 |
312 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
62 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,842 |
1,342 |
$6K |
| D1354 |
|
2,058 |
505 |
$6K |
| D0274 |
Bitewings - four radiographic images |
422 |
391 |
$5K |