| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,302 |
811 |
$344K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,296 |
2,558 |
$299K |
| D0120 |
Periodic oral evaluation - established patient |
10,106 |
10,065 |
$287K |
| D1120 |
Prophylaxis - child |
11,001 |
10,910 |
$262K |
| D1206 |
Topical application of fluoride varnish |
10,785 |
10,695 |
$228K |
| D1351 |
Sealant - per tooth |
8,442 |
2,354 |
$205K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,109 |
1,243 |
$120K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,377 |
4,039 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,573 |
856 |
$83K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
750 |
419 |
$69K |
| D9999 |
Unspecified adjunctive procedure, by report |
2,111 |
2,080 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,636 |
1,578 |
$63K |
| D0330 |
Panoramic radiographic image |
1,290 |
1,278 |
$49K |
| D0272 |
Bitewings - two radiographic images |
4,898 |
4,846 |
$48K |
| D2390 |
|
210 |
69 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
639 |
516 |
$44K |
| D1110 |
Prophylaxis - adult |
629 |
622 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
857 |
839 |
$18K |
| D0240 |
|
1,889 |
982 |
$16K |
| D2331 |
|
88 |
56 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
634 |
$5K |
| D2330 |
|
39 |
26 |
$2K |
| D7111 |
|
14 |
12 |
$435.89 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$180.36 |