| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,505 |
1,594 |
$1.07M |
| D1120 |
Prophylaxis - child |
7,791 |
7,762 |
$325K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,392 |
1,281 |
$285K |
| D1206 |
Topical application of fluoride varnish |
7,494 |
7,465 |
$210K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,954 |
957 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
4,803 |
4,795 |
$161K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
728 |
432 |
$89K |
| D1351 |
Sealant - per tooth |
2,802 |
1,057 |
$86K |
| D0272 |
Bitewings - two radiographic images |
3,368 |
3,360 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
826 |
530 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,132 |
1,128 |
$68K |
| D0240 |
|
2,876 |
1,489 |
$60K |
| D9310 |
|
768 |
766 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
915 |
896 |
$54K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,010 |
1,008 |
$40K |
| D1354 |
|
1,375 |
448 |
$37K |
| D0330 |
Panoramic radiographic image |
419 |
418 |
$32K |
| D2934 |
|
106 |
27 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
815 |
796 |
$15K |
| D9420 |
|
107 |
105 |
$14K |
| D1510 |
|
23 |
14 |
$4K |
| D9248 |
|
26 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
15 |
$292.04 |