| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,904 |
923 |
$321K |
| D0120 |
Periodic oral evaluation - established patient |
5,853 |
5,815 |
$171K |
| D1120 |
Prophylaxis - child |
5,374 |
5,317 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,539 |
1,014 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
868 |
652 |
$50K |
| D1206 |
Topical application of fluoride varnish |
7,338 |
7,294 |
$50K |
| D1110 |
Prophylaxis - adult |
1,202 |
1,197 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,211 |
915 |
$48K |
| D1351 |
Sealant - per tooth |
4,570 |
1,467 |
$42K |
| D0330 |
Panoramic radiographic image |
611 |
605 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
991 |
984 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,651 |
1,490 |
$28K |
| D0272 |
Bitewings - two radiographic images |
5,326 |
5,268 |
$19K |
| D9420 |
|
191 |
180 |
$13K |
| D1354 |
|
1,919 |
590 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
1,107 |
1,085 |
$12K |
| D1330 |
|
7,035 |
6,996 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
317 |
316 |
$10K |
| D0240 |
|
2,017 |
1,795 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,852 |
1,747 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
229 |
229 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
639 |
374 |
$3K |
| D7111 |
|
87 |
50 |
$2K |
| D1999 |
|
32 |
32 |
$2K |
| D0274 |
Bitewings - four radiographic images |
607 |
604 |
$2K |
| D2940 |
|
127 |
110 |
$2K |
| D9248 |
|
28 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
60 |
60 |
$1K |
| D2330 |
|
36 |
25 |
$952.31 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
25 |
$891.90 |
| D2331 |
|
29 |
14 |
$631.92 |
| D3120 |
|
77 |
52 |
$561.94 |