| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,883 |
965 |
$434K |
| D0120 |
Periodic oral evaluation - established patient |
13,335 |
12,937 |
$369K |
| D1120 |
Prophylaxis - child |
13,405 |
12,959 |
$267K |
| D1206 |
Topical application of fluoride varnish |
13,847 |
13,360 |
$242K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,740 |
2,003 |
$226K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,211 |
3,000 |
$134K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,920 |
1,229 |
$134K |
| D9999 |
Unspecified adjunctive procedure, by report |
4,714 |
4,446 |
$116K |
| D1351 |
Sealant - per tooth |
5,592 |
1,932 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,224 |
753 |
$59K |
| D7961 |
|
707 |
612 |
$58K |
| D7962 |
|
713 |
633 |
$57K |
| D0330 |
Panoramic radiographic image |
1,507 |
1,473 |
$52K |
| D1110 |
Prophylaxis - adult |
1,670 |
1,616 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,757 |
2,483 |
$48K |
| D0272 |
Bitewings - two radiographic images |
5,423 |
5,184 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
678 |
406 |
$44K |
| D0240 |
|
6,548 |
3,187 |
$40K |
| D7960 |
|
396 |
224 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
1,691 |
1,597 |
$35K |
| D1354 |
|
8,690 |
3,062 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
421 |
200 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,534 |
2,118 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,536 |
2,418 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,145 |
1,120 |
$14K |
| D2929 |
|
43 |
15 |
$9K |
| D1999 |
|
2,059 |
1,886 |
$9K |
| D2332 |
|
24 |
12 |
$2K |
| D9440 |
|
20 |
19 |
$575.64 |
| D0350 |
|
596 |
480 |
$58.25 |
| D9430 |
|
156 |
136 |
$0.00 |
| D0603 |
|
3,963 |
3,689 |
$0.00 |
| D3120 |
|
13 |
12 |
$0.00 |