| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25,357 |
6,579 |
$4.57M |
| D1120 |
Prophylaxis - child |
50,332 |
49,697 |
$2.04M |
| D0120 |
Periodic oral evaluation - established patient |
61,518 |
60,784 |
$1.93M |
| D1206 |
Topical application of fluoride varnish |
74,084 |
73,123 |
$1.83M |
| D1351 |
Sealant - per tooth |
40,133 |
8,546 |
$1.32M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13,334 |
7,343 |
$1.30M |
| D7140 |
Extraction, erupted tooth or exposed root |
14,515 |
7,128 |
$1.25M |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12,769 |
7,267 |
$1.05M |
| D1110 |
Prophylaxis - adult |
18,465 |
18,224 |
$1.03M |
| D0272 |
Bitewings - two radiographic images |
32,078 |
31,688 |
$928K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
8,566 |
4,235 |
$887K |
| D2390 |
|
4,204 |
1,491 |
$828K |
| D9420 |
|
5,000 |
4,925 |
$827K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17,095 |
16,456 |
$655K |
| D0210 |
Intraoral - complete series of radiographic images |
5,353 |
5,282 |
$529K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
9,876 |
9,708 |
$491K |
| D0274 |
Bitewings - four radiographic images |
9,278 |
9,136 |
$352K |
| D2330 |
|
3,468 |
2,145 |
$314K |
| D1510 |
|
1,710 |
1,327 |
$303K |
| D2331 |
|
2,750 |
1,695 |
$299K |
| D0145 |
Oral evaluation for a patient under three years of age |
7,466 |
7,356 |
$244K |
| D0220 |
Intraoral - periapical first radiographic image |
14,028 |
13,763 |
$244K |
| D1330 |
|
7,255 |
7,157 |
$168K |
| D0140 |
Limited oral evaluation - problem focused |
3,553 |
3,487 |
$158K |
| D0330 |
Panoramic radiographic image |
1,992 |
1,973 |
$143K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,806 |
8,263 |
$113K |
| D8670 |
Periodic orthodontic treatment visit |
58 |
58 |
$73K |
| D3230 |
|
931 |
364 |
$71K |
| D2934 |
|
145 |
41 |
$28K |
| D2332 |
|
216 |
149 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
145 |
118 |
$16K |
| D7111 |
|
184 |
119 |
$12K |
| D2931 |
|
50 |
29 |
$8K |
| D2920 |
|
67 |
52 |
$4K |
| D3120 |
|
15 |
12 |
$902.55 |