| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,057 |
2,630 |
$1.14M |
| D1120 |
Prophylaxis - child |
25,378 |
25,368 |
$1.02M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
8,455 |
4,133 |
$1.00M |
| D0120 |
Periodic oral evaluation - established patient |
27,246 |
27,233 |
$884K |
| D1206 |
Topical application of fluoride varnish |
28,301 |
28,282 |
$747K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,309 |
2,704 |
$457K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,780 |
3,031 |
$432K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,050 |
1,659 |
$385K |
| D0272 |
Bitewings - two radiographic images |
13,705 |
13,686 |
$312K |
| D1351 |
Sealant - per tooth |
9,900 |
2,858 |
$288K |
| D1110 |
Prophylaxis - adult |
3,610 |
3,610 |
$175K |
| D2332 |
|
1,246 |
789 |
$148K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,570 |
2,570 |
$141K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
930 |
675 |
$133K |
| D2330 |
|
1,424 |
928 |
$110K |
| D9248 |
|
1,641 |
1,637 |
$107K |
| D0330 |
Panoramic radiographic image |
1,548 |
1,548 |
$98K |
| D0140 |
Limited oral evaluation - problem focused |
1,558 |
1,539 |
$91K |
| D0240 |
|
4,095 |
2,784 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
1,092 |
1,054 |
$78K |
| D1510 |
|
394 |
325 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
3,204 |
3,165 |
$56K |
| D2934 |
|
220 |
77 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,598 |
1,277 |
$33K |
| D0145 |
Oral evaluation for a patient under three years of age |
652 |
652 |
$26K |
| D2331 |
|
119 |
88 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
151 |
$4K |
| D9986 |
|
1,139 |
1,126 |
$0.00 |