| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,703 |
646 |
$363K |
| D1120 |
Prophylaxis - child |
6,519 |
6,203 |
$207K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,198 |
987 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,236 |
1,140 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
6,368 |
6,029 |
$144K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,514 |
726 |
$133K |
| D1110 |
Prophylaxis - adult |
2,702 |
2,522 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,485 |
5,175 |
$104K |
| D0274 |
Bitewings - four radiographic images |
3,839 |
3,616 |
$92K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,262 |
440 |
$90K |
| D0330 |
Panoramic radiographic image |
2,479 |
2,347 |
$90K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,359 |
1,883 |
$64K |
| D1206 |
Topical application of fluoride varnish |
3,214 |
3,071 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
992 |
578 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,570 |
1,271 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,592 |
1,523 |
$43K |
| D2394 |
|
364 |
154 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,580 |
2,295 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,473 |
1,394 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
861 |
819 |
$19K |
| D1351 |
Sealant - per tooth |
96 |
28 |
$3K |
| D2920 |
|
15 |
12 |
$614.32 |
| D1999 |
|
22 |
19 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
65 |
63 |
$0.00 |