| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18,040 |
2,152 |
$2.60M |
| D1120 |
Prophylaxis - child |
11,670 |
10,907 |
$674K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,347 |
1,273 |
$539K |
| D1351 |
Sealant - per tooth |
10,039 |
1,873 |
$438K |
| D3240 |
|
1,552 |
466 |
$426K |
| D1206 |
Topical application of fluoride varnish |
15,253 |
13,274 |
$392K |
| D0120 |
Periodic oral evaluation - established patient |
8,797 |
8,302 |
$381K |
| D0272 |
Bitewings - two radiographic images |
9,214 |
8,621 |
$340K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,663 |
3,421 |
$220K |
| D0240 |
|
6,132 |
3,069 |
$172K |
| D0330 |
Panoramic radiographic image |
1,748 |
1,605 |
$153K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,005 |
2,306 |
$136K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
759 |
337 |
$90K |
| D0220 |
Intraoral - periapical first radiographic image |
3,409 |
3,075 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
142 |
$51K |
| D2390 |
|
78 |
25 |
$19K |
| D0274 |
Bitewings - four radiographic images |
338 |
320 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
56 |
$17K |
| D1110 |
Prophylaxis - adult |
148 |
143 |
$12K |
| D2332 |
|
34 |
13 |
$6K |
| D2330 |
|
51 |
25 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
69 |
$4K |
| D9420 |
|
25 |
13 |
$1K |