| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
11,552 |
2,896 |
$2.32M |
| D7140 |
Extraction, erupted tooth or exposed root |
7,465 |
2,702 |
$665K |
| D2934 |
|
2,492 |
815 |
$551K |
| D1120 |
Prophylaxis - child |
11,410 |
11,399 |
$465K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,806 |
2,157 |
$451K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,289 |
1,266 |
$419K |
| D1206 |
Topical application of fluoride varnish |
12,024 |
12,012 |
$337K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,173 |
1,954 |
$283K |
| D0120 |
Periodic oral evaluation - established patient |
8,197 |
8,196 |
$275K |
| D0140 |
Limited oral evaluation - problem focused |
3,606 |
3,566 |
$227K |
| D1351 |
Sealant - per tooth |
6,237 |
2,069 |
$202K |
| D2929 |
|
800 |
255 |
$177K |
| D9310 |
|
1,575 |
1,575 |
$124K |
| D0272 |
Bitewings - two radiographic images |
4,994 |
4,986 |
$121K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,827 |
3,415 |
$115K |
| D0240 |
|
5,953 |
3,244 |
$112K |
| D0220 |
Intraoral - periapical first radiographic image |
4,632 |
4,576 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,052 |
1,052 |
$68K |
| D1510 |
|
279 |
175 |
$57K |
| D0330 |
Panoramic radiographic image |
602 |
601 |
$41K |
| D9420 |
|
242 |
241 |
$34K |
| D9248 |
|
615 |
606 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
1,131 |
710 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
439 |
439 |
$18K |
| D1110 |
Prophylaxis - adult |
220 |
220 |
$10K |
| D0191 |
|
338 |
338 |
$7K |
| D1354 |
|
170 |
74 |
$4K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$4K |
| D9996 |
|
149 |
148 |
$0.00 |
| D3120 |
|
522 |
288 |
$0.00 |
| D0602 |
|
1,347 |
1,346 |
$0.00 |
| D0603 |
|
5,687 |
5,682 |
$0.00 |
| D0601 |
|
23 |
23 |
$0.00 |
| D1330 |
|
13 |
13 |
$0.00 |