| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,872 |
2,239 |
$1.70M |
| D1120 |
Prophylaxis - child |
10,359 |
10,356 |
$404K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,108 |
1,939 |
$355K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,663 |
2,375 |
$331K |
| D0120 |
Periodic oral evaluation - established patient |
8,796 |
8,795 |
$280K |
| D1206 |
Topical application of fluoride varnish |
10,397 |
10,397 |
$276K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,094 |
1,581 |
$254K |
| D9420 |
|
1,411 |
1,411 |
$199K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,571 |
850 |
$195K |
| D0272 |
Bitewings - two radiographic images |
5,269 |
5,265 |
$116K |
| D1351 |
Sealant - per tooth |
3,402 |
1,490 |
$96K |
| D2934 |
|
411 |
123 |
$95K |
| D0240 |
|
2,704 |
1,823 |
$46K |
| D9310 |
|
614 |
614 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
877 |
876 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
357 |
355 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,212 |
1,208 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
590 |
589 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
295 |
$10K |
| D2331 |
|
71 |
48 |
$8K |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$4K |
| D1510 |
|
16 |
12 |
$3K |
| D1354 |
|
39 |
32 |
$990.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$516.00 |