| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,733 |
420 |
$314K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,138 |
1,436 |
$242K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,819 |
1,192 |
$183K |
| D1206 |
Topical application of fluoride varnish |
4,964 |
4,926 |
$125K |
| D1120 |
Prophylaxis - child |
4,181 |
4,167 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,133 |
3,130 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,984 |
1,974 |
$86K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
701 |
267 |
$79K |
| D1351 |
Sealant - per tooth |
2,845 |
831 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,976 |
1,861 |
$47K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,276 |
1,273 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
5,278 |
5,154 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
717 |
359 |
$39K |
| D1110 |
Prophylaxis - adult |
909 |
907 |
$39K |
| D9630 |
|
866 |
828 |
$35K |
| D2390 |
|
122 |
52 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
1,236 |
1,217 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,463 |
4,833 |
$28K |
| D9248 |
|
413 |
407 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,784 |
2,779 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
319 |
231 |
$26K |
| D0330 |
Panoramic radiographic image |
976 |
966 |
$24K |
| D2331 |
|
53 |
39 |
$6K |
| D0274 |
Bitewings - four radiographic images |
249 |
247 |
$3K |
| D2330 |
|
19 |
12 |
$2K |
| D7111 |
|
24 |
12 |
$771.19 |
| D1330 |
|
12 |
12 |
$0.00 |