| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,280 |
785 |
$584K |
| D0120 |
Periodic oral evaluation - established patient |
11,934 |
11,877 |
$330K |
| D1120 |
Prophylaxis - child |
13,610 |
13,532 |
$316K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,602 |
2,232 |
$312K |
| D1206 |
Topical application of fluoride varnish |
11,786 |
11,719 |
$237K |
| D9999 |
Unspecified adjunctive procedure, by report |
6,801 |
6,711 |
$202K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,837 |
1,520 |
$151K |
| D1351 |
Sealant - per tooth |
4,513 |
1,551 |
$94K |
| D2929 |
|
295 |
92 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,798 |
1,773 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,423 |
3,234 |
$67K |
| D0272 |
Bitewings - two radiographic images |
6,454 |
6,423 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
6,833 |
6,729 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
2,324 |
2,262 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
663 |
398 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,298 |
1,293 |
$35K |
| D1999 |
|
2,609 |
2,436 |
$33K |
| D0330 |
Panoramic radiographic image |
505 |
500 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,263 |
5,743 |
$15K |
| D7962 |
|
136 |
126 |
$12K |
| D9920 |
|
319 |
308 |
$11K |
| D7960 |
|
100 |
71 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
91 |
52 |
$9K |
| D7961 |
|
91 |
88 |
$8K |
| D1354 |
|
1,745 |
550 |
$6K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$3K |
| D9310 |
|
24 |
23 |
$2K |
| D0240 |
|
165 |
86 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D2331 |
|
15 |
12 |
$897.26 |
| D0270 |
|
29 |
28 |
$221.76 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$195.39 |