| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,121 |
860 |
$593K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,157 |
704 |
$115K |
| D1351 |
Sealant - per tooth |
4,559 |
961 |
$110K |
| D1206 |
Topical application of fluoride varnish |
4,122 |
4,050 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,198 |
2,133 |
$83K |
| D1120 |
Prophylaxis - child |
4,186 |
4,099 |
$81K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
833 |
279 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,448 |
2,420 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,054 |
478 |
$60K |
| D0330 |
Panoramic radiographic image |
834 |
811 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
1,110 |
1,057 |
$23K |
| D0240 |
|
2,834 |
1,415 |
$22K |
| D0272 |
Bitewings - two radiographic images |
2,313 |
2,234 |
$22K |
| D2390 |
|
36 |
13 |
$10K |
| D1999 |
|
532 |
437 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
289 |
228 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
39 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
240 |
236 |
$4K |
| D1110 |
Prophylaxis - adult |
99 |
98 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
489 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
95 |
94 |
$2K |
| D2330 |
|
31 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
282 |
235 |
$651.75 |
| D1354 |
|
168 |
28 |
$465.00 |