| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,076 |
1,105 |
$642K |
| D0120 |
Periodic oral evaluation - established patient |
12,180 |
12,061 |
$337K |
| D1120 |
Prophylaxis - child |
13,470 |
13,275 |
$321K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,884 |
1,879 |
$282K |
| D1206 |
Topical application of fluoride varnish |
12,608 |
12,426 |
$254K |
| D9999 |
Unspecified adjunctive procedure, by report |
3,483 |
3,416 |
$103K |
| D0272 |
Bitewings - two radiographic images |
8,597 |
8,473 |
$87K |
| D1351 |
Sealant - per tooth |
3,028 |
710 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,649 |
1,566 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,495 |
2,417 |
$57K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
608 |
360 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
4,458 |
4,163 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
313 |
165 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
489 |
238 |
$28K |
| D1999 |
|
1,351 |
1,308 |
$17K |
| D2929 |
|
68 |
25 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,979 |
2,765 |
$13K |
| D9630 |
|
293 |
291 |
$13K |
| D0330 |
Panoramic radiographic image |
164 |
161 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
103 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
71 |
$2K |
| D1354 |
|
41 |
14 |
$123.00 |
| D3120 |
|
31 |
15 |
$0.00 |