| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
9,546 |
1,775 |
$1.04M |
| D1120 |
Prophylaxis - child |
16,525 |
16,408 |
$484K |
| D8670 |
Periodic orthodontic treatment visit |
1,323 |
1,301 |
$483K |
| D0120 |
Periodic oral evaluation - established patient |
16,643 |
16,517 |
$293K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,910 |
2,252 |
$241K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,922 |
1,441 |
$223K |
| D1206 |
Topical application of fluoride varnish |
12,312 |
12,154 |
$201K |
| D1110 |
Prophylaxis - adult |
4,480 |
4,435 |
$172K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,075 |
8,074 |
$166K |
| D1351 |
Sealant - per tooth |
5,552 |
1,706 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,902 |
3,872 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,500 |
1,027 |
$110K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,552 |
3,338 |
$103K |
| D2932 |
|
974 |
308 |
$101K |
| D0272 |
Bitewings - two radiographic images |
4,718 |
4,681 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
3,310 |
3,028 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,740 |
2,585 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,895 |
2,855 |
$62K |
| D9310 |
|
467 |
465 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,466 |
3,414 |
$32K |
| D8660 |
|
150 |
149 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
436 |
246 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,101 |
1,071 |
$26K |
| D0330 |
Panoramic radiographic image |
494 |
487 |
$23K |
| D8090 |
|
12 |
12 |
$21K |
| D0240 |
|
1,913 |
1,174 |
$18K |
| D3120 |
|
1,220 |
732 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D9920 |
|
13 |
13 |
$890.50 |