| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,141 |
1,111 |
$812K |
| D1120 |
Prophylaxis - child |
5,741 |
5,739 |
$228K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,555 |
1,034 |
$213K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,508 |
835 |
$178K |
| D1206 |
Topical application of fluoride varnish |
5,847 |
5,845 |
$159K |
| D0120 |
Periodic oral evaluation - established patient |
4,248 |
4,247 |
$140K |
| D2934 |
|
627 |
194 |
$136K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,202 |
722 |
$106K |
| D9310 |
|
1,248 |
1,247 |
$93K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
748 |
259 |
$92K |
| D0140 |
Limited oral evaluation - problem focused |
1,330 |
1,322 |
$81K |
| D1351 |
Sealant - per tooth |
2,141 |
734 |
$67K |
| D0272 |
Bitewings - two radiographic images |
2,490 |
2,489 |
$59K |
| D0240 |
|
2,647 |
1,469 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,528 |
1,384 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
625 |
625 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,892 |
1,884 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
274 |
206 |
$10K |
| D9248 |
|
221 |
218 |
$9K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
191 |
191 |
$8K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
60 |
16 |
$5K |
| D1510 |
|
25 |
14 |
$4K |
| D0191 |
|
162 |
162 |
$3K |
| D9222 |
|
16 |
16 |
$2K |
| D0603 |
|
3,026 |
3,019 |
$0.00 |
| D0602 |
|
436 |
436 |
$0.00 |
| D3120 |
|
70 |
41 |
$0.00 |
| D7960 |
|
17 |
15 |
$0.00 |
| D9996 |
|
179 |
178 |
$0.00 |