| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
11,303 |
3,273 |
$1.25M |
| D1120 |
Prophylaxis - child |
24,158 |
23,869 |
$759K |
| D0120 |
Periodic oral evaluation - established patient |
28,383 |
28,069 |
$658K |
| D1208 |
Topical application of fluoride, excluding varnish |
27,952 |
27,626 |
$545K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
7,942 |
4,306 |
$473K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,309 |
1,887 |
$350K |
| D1351 |
Sealant - per tooth |
10,994 |
4,096 |
$306K |
| D9248 |
|
3,578 |
3,417 |
$300K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,441 |
2,288 |
$247K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,007 |
2,070 |
$240K |
| D1110 |
Prophylaxis - adult |
5,689 |
5,643 |
$236K |
| D0330 |
Panoramic radiographic image |
4,264 |
4,205 |
$193K |
| D0272 |
Bitewings - two radiographic images |
10,576 |
10,435 |
$179K |
| D2929 |
|
1,492 |
509 |
$166K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,317 |
3,194 |
$95K |
| D1206 |
Topical application of fluoride varnish |
4,127 |
4,092 |
$80K |
| D1353 |
|
3,128 |
1,148 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,338 |
2,316 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
4,909 |
4,791 |
$59K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,226 |
2,208 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
1,757 |
1,738 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,160 |
2,613 |
$38K |
| D2330 |
|
280 |
209 |
$16K |
| D0274 |
Bitewings - four radiographic images |
234 |
232 |
$6K |
| D2331 |
|
19 |
13 |
$1K |
| D2920 |
|
34 |
27 |
$1K |
| D9420 |
|
1,426 |
1,406 |
$0.00 |