| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 41899 |
Unlisted procedure, dentoalveolar structures |
4,880 |
2,806 |
$5.07M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,057 |
4,073 |
$3.91M |
| D2933 |
|
1,319 |
620 |
$517K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,319 |
2,160 |
$424K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
804 |
523 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,686 |
1,141 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
3,532 |
3,410 |
$31K |
| D2929 |
|
14 |
14 |
$21K |
| D2330 |
|
332 |
168 |
$12K |
| D3230 |
|
383 |
170 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,881 |
1,386 |
$8K |
| D1120 |
Prophylaxis - child |
3,325 |
3,199 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
163 |
121 |
$4K |
| D2331 |
|
167 |
103 |
$2K |
| D0240 |
|
3,723 |
2,373 |
$500.00 |
| D0220 |
Intraoral - periapical first radiographic image |
2,938 |
2,830 |
$0.00 |
| D1510 |
|
163 |
92 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
3,616 |
3,484 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,807 |
2,825 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
2,888 |
2,781 |
$0.00 |
| D1351 |
Sealant - per tooth |
153 |
78 |
$0.00 |