| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,947 |
378 |
$337K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,097 |
1,429 |
$228K |
| D0120 |
Periodic oral evaluation - established patient |
6,208 |
6,115 |
$181K |
| D1206 |
Topical application of fluoride varnish |
6,852 |
6,726 |
$153K |
| D1120 |
Prophylaxis - child |
5,984 |
5,879 |
$144K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,748 |
995 |
$97K |
| D9630 |
|
1,660 |
1,597 |
$69K |
| D1351 |
Sealant - per tooth |
2,699 |
911 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
7,465 |
7,167 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,398 |
1,358 |
$58K |
| D1110 |
Prophylaxis - adult |
1,343 |
1,317 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
910 |
442 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
2,015 |
1,956 |
$46K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
159 |
159 |
$38K |
| D0272 |
Bitewings - two radiographic images |
3,701 |
3,649 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,719 |
6,571 |
$34K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,033 |
1,010 |
$34K |
| D0330 |
Panoramic radiographic image |
952 |
937 |
$33K |
| D8670 |
Periodic orthodontic treatment visit |
137 |
129 |
$29K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
148 |
65 |
$14K |
| D2390 |
|
44 |
12 |
$13K |
| D0160 |
|
202 |
199 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
473 |
464 |
$8K |
| D0274 |
Bitewings - four radiographic images |
545 |
524 |
$6K |
| D2332 |
|
42 |
25 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
25 |
$3K |
| D2330 |
|
43 |
25 |
$2K |
| D1354 |
|
205 |
56 |
$814.80 |
| D9920 |
|
26 |
26 |
$750.27 |
| D1330 |
|
260 |
259 |
$0.00 |