| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,676 |
1,857 |
$1.29M |
| D1120 |
Prophylaxis - child |
9,398 |
8,930 |
$381K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,919 |
1,079 |
$372K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,223 |
1,510 |
$277K |
| D1206 |
Topical application of fluoride varnish |
9,563 |
9,086 |
$255K |
| D0120 |
Periodic oral evaluation - established patient |
7,834 |
7,726 |
$251K |
| D1351 |
Sealant - per tooth |
7,904 |
1,889 |
$242K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,272 |
631 |
$151K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,373 |
814 |
$127K |
| D2934 |
|
540 |
245 |
$123K |
| D0272 |
Bitewings - two radiographic images |
4,971 |
4,709 |
$112K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,607 |
3,281 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,177 |
2,154 |
$95K |
| D0220 |
Intraoral - periapical first radiographic image |
4,661 |
4,409 |
$85K |
| D9920 |
|
1,122 |
1,104 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
641 |
619 |
$39K |
| D1510 |
|
177 |
133 |
$34K |
| D9420 |
|
81 |
79 |
$13K |
| D2390 |
|
32 |
12 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
157 |
148 |
$7K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$6K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$4K |
| D9248 |
|
50 |
50 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,277 |
2,245 |
$0.00 |