| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,803 |
564 |
$337K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,146 |
3,771 |
$214K |
| D9910 |
|
3,411 |
3,048 |
$139K |
| D0350 |
|
2,422 |
2,234 |
$124K |
| D1120 |
Prophylaxis - child |
2,151 |
2,137 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
4,354 |
4,050 |
$75K |
| D0140 |
Limited oral evaluation - problem focused |
1,529 |
1,402 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,894 |
1,882 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
620 |
272 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,399 |
2,382 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
660 |
651 |
$42K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
431 |
195 |
$39K |
| D0240 |
|
1,349 |
1,282 |
$33K |
| D1351 |
Sealant - per tooth |
798 |
256 |
$21K |
| D2390 |
|
104 |
38 |
$18K |
| D9420 |
|
78 |
78 |
$11K |
| D0272 |
Bitewings - two radiographic images |
418 |
416 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
65 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
34 |
$6K |
| D1110 |
Prophylaxis - adult |
99 |
99 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$2K |
| D0171 |
|
12 |
12 |
$510.95 |