| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,067 |
349 |
$121K |
| D1120 |
Prophylaxis - child |
5,161 |
5,079 |
$109K |
| D1351 |
Sealant - per tooth |
5,369 |
1,115 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
3,706 |
3,683 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,401 |
629 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,243 |
2,173 |
$78K |
| D1206 |
Topical application of fluoride varnish |
3,701 |
3,632 |
$59K |
| D9999 |
Unspecified adjunctive procedure, by report |
2,303 |
2,261 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,030 |
511 |
$49K |
| D0330 |
Panoramic radiographic image |
971 |
948 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,972 |
1,946 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,724 |
1,482 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,766 |
2,721 |
$27K |
| D1999 |
|
1,848 |
1,538 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
352 |
142 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,862 |
2,742 |
$22K |
| D0240 |
|
2,289 |
1,145 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
181 |
$18K |
| D1110 |
Prophylaxis - adult |
486 |
484 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
858 |
793 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,690 |
2,233 |
$16K |
| D0274 |
Bitewings - four radiographic images |
387 |
384 |
$5K |
| D9920 |
|
140 |
135 |
$4K |
| D7111 |
|
16 |
13 |
$459.20 |