| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,250 |
484 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
5,838 |
5,712 |
$134K |
| D1206 |
Topical application of fluoride varnish |
6,424 |
6,184 |
$99K |
| D1120 |
Prophylaxis - child |
4,000 |
3,877 |
$87K |
| D1351 |
Sealant - per tooth |
3,029 |
839 |
$58K |
| D1110 |
Prophylaxis - adult |
1,500 |
1,459 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
811 |
555 |
$49K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,792 |
1,696 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,149 |
2,029 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
794 |
553 |
$37K |
| D0330 |
Panoramic radiographic image |
1,074 |
1,007 |
$36K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
523 |
360 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
560 |
349 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
867 |
749 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,628 |
2,546 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,787 |
2,633 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,956 |
1,889 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,336 |
1,923 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
139 |
77 |
$10K |
| D0240 |
|
1,452 |
788 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
488 |
456 |
$9K |
| D2140 |
|
141 |
102 |
$7K |
| D2160 |
|
92 |
78 |
$6K |
| D7111 |
|
150 |
99 |
$4K |
| D0273 |
|
371 |
365 |
$3K |
| D9920 |
|
109 |
98 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
30 |
$2K |
| D2335 |
|
19 |
12 |
$1K |
| D2332 |
|
18 |
12 |
$1K |
| D0270 |
|
161 |
149 |
$815.76 |
| D0602 |
|
1,873 |
1,811 |
$0.00 |
| D1330 |
|
6,790 |
6,538 |
$0.00 |
| D0601 |
|
1,592 |
1,523 |
$0.00 |
| D0603 |
|
3,114 |
3,016 |
$0.00 |
| D1353 |
|
33 |
15 |
$0.00 |
| D9219 |
|
24 |
24 |
$0.00 |
| D0350 |
|
43 |
40 |
$0.00 |