| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,400 |
705 |
$405K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,255 |
1,564 |
$302K |
| D1120 |
Prophylaxis - child |
8,033 |
7,985 |
$187K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,284 |
1,227 |
$184K |
| D0120 |
Periodic oral evaluation - established patient |
5,955 |
5,933 |
$177K |
| D1206 |
Topical application of fluoride varnish |
8,020 |
7,939 |
$174K |
| D9999 |
Unspecified adjunctive procedure, by report |
3,718 |
3,690 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,594 |
2,563 |
$107K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,755 |
813 |
$99K |
| D0140 |
Limited oral evaluation - problem focused |
4,506 |
4,359 |
$96K |
| D7240 |
Removal of impacted tooth - completely bony |
619 |
177 |
$92K |
| D1351 |
Sealant - per tooth |
3,576 |
961 |
$82K |
| D9920 |
|
1,869 |
1,808 |
$57K |
| D7961 |
|
551 |
543 |
$53K |
| D9630 |
|
1,188 |
1,162 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,381 |
2,203 |
$51K |
| D7962 |
|
413 |
409 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
4,199 |
4,040 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,039 |
2,026 |
$21K |
| D1999 |
|
1,378 |
1,242 |
$17K |
| D7960 |
|
173 |
100 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,569 |
3,436 |
$15K |
| D2390 |
|
46 |
12 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
56 |
$7K |
| D7230 |
|
36 |
15 |
$5K |
| D0330 |
Panoramic radiographic image |
77 |
75 |
$3K |
| D2332 |
|
18 |
12 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
12 |
$1K |
| D9248 |
|
12 |
12 |
$840.00 |
| D1354 |
|
192 |
56 |
$732.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
30 |
$420.84 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$398.75 |