| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,487 |
2,219 |
$1.10M |
| D1354 |
|
13,877 |
8,165 |
$504K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,519 |
3,309 |
$191K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,678 |
1,183 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,636 |
1,165 |
$159K |
| D1351 |
Sealant - per tooth |
2,108 |
1,353 |
$138K |
| D1120 |
Prophylaxis - child |
3,372 |
3,191 |
$133K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
909 |
685 |
$125K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,738 |
7,555 |
$122K |
| D1510 |
|
1,272 |
1,080 |
$120K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,328 |
952 |
$113K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,400 |
4,255 |
$106K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
810 |
707 |
$83K |
| D1206 |
Topical application of fluoride varnish |
3,922 |
3,841 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,500 |
2,361 |
$70K |
| D2335 |
|
384 |
254 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,756 |
2,520 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
8,166 |
7,634 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
465 |
346 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
1,451 |
1,374 |
$20K |
| D4342 |
|
137 |
65 |
$19K |
| D0999 |
Unspecified diagnostic procedure, by report |
184 |
146 |
$19K |
| D0330 |
Panoramic radiographic image |
776 |
741 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
1,207 |
1,159 |
$14K |
| D9920 |
|
2,247 |
2,179 |
$11K |
| D0272 |
Bitewings - two radiographic images |
1,031 |
1,012 |
$10K |
| D0270 |
|
1,185 |
1,175 |
$7K |
| D2394 |
|
38 |
24 |
$3K |
| D7510 |
|
262 |
242 |
$3K |
| D9110 |
|
70 |
69 |
$1K |
| D0274 |
Bitewings - four radiographic images |
141 |
119 |
$1K |
| D9310 |
|
77 |
73 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$615.00 |
| D1310 |
|
982 |
971 |
$29.26 |
| D9994 |
|
262 |
258 |
$0.00 |
| D1355 |
|
384 |
233 |
$0.00 |
| D9997 |
|
263 |
259 |
$0.00 |
| D9990 |
|
29 |
29 |
$0.00 |
| D0350 |
|
171 |
171 |
$0.00 |