| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,798 |
449 |
$189K |
| D0120 |
Periodic oral evaluation - established patient |
5,438 |
5,310 |
$118K |
| D1120 |
Prophylaxis - child |
5,600 |
5,458 |
$113K |
| D1206 |
Topical application of fluoride varnish |
6,055 |
5,847 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,189 |
684 |
$63K |
| D9999 |
Unspecified adjunctive procedure, by report |
2,583 |
2,317 |
$59K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
908 |
300 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,106 |
480 |
$52K |
| D7960 |
|
554 |
325 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,216 |
1,136 |
$39K |
| D1351 |
Sealant - per tooth |
2,248 |
789 |
$38K |
| D0330 |
Panoramic radiographic image |
871 |
843 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
1,335 |
1,161 |
$23K |
| D1110 |
Prophylaxis - adult |
649 |
630 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,134 |
1,032 |
$19K |
| D0240 |
|
2,584 |
1,287 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,931 |
1,869 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
109 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,680 |
886 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,136 |
1,035 |
$7K |
| D2929 |
|
32 |
13 |
$7K |
| D0274 |
Bitewings - four radiographic images |
475 |
459 |
$6K |
| D1354 |
|
1,884 |
837 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
58 |
$4K |
| D7962 |
|
26 |
25 |
$0.00 |
| D9440 |
|
23 |
19 |
$0.00 |
| D7961 |
|
24 |
23 |
$0.00 |
| D1999 |
|
18 |
18 |
$0.00 |