| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
9,627 |
3,719 |
$1.90M |
| D1120 |
Prophylaxis - child |
21,944 |
21,937 |
$933K |
| D1206 |
Topical application of fluoride varnish |
23,206 |
23,198 |
$662K |
| D0120 |
Periodic oral evaluation - established patient |
18,080 |
18,075 |
$619K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,097 |
2,531 |
$517K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,917 |
1,933 |
$378K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,164 |
2,422 |
$374K |
| D1354 |
|
11,071 |
2,802 |
$271K |
| D1352 |
|
4,082 |
1,594 |
$260K |
| D0272 |
Bitewings - two radiographic images |
10,960 |
10,953 |
$259K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,221 |
4,221 |
$244K |
| D0220 |
Intraoral - periapical first radiographic image |
10,191 |
9,673 |
$191K |
| D2390 |
|
895 |
364 |
$183K |
| D9248 |
|
2,236 |
2,167 |
$148K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,463 |
1,130 |
$142K |
| D1510 |
|
634 |
538 |
$123K |
| D9310 |
|
1,537 |
1,536 |
$110K |
| D1110 |
Prophylaxis - adult |
1,756 |
1,755 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,133 |
4,481 |
$83K |
| D1351 |
Sealant - per tooth |
2,742 |
1,018 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
1,366 |
1,357 |
$82K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,413 |
1,412 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,398 |
1,398 |
$55K |
| D9920 |
|
1,064 |
1,052 |
$49K |
| D2929 |
|
166 |
45 |
$41K |
| D2330 |
|
444 |
334 |
$37K |
| D2332 |
|
266 |
191 |
$34K |
| D9420 |
|
74 |
73 |
$12K |
| D1517 |
|
28 |
28 |
$7K |
| D7111 |
|
89 |
72 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$947.23 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$935.00 |
| D3120 |
|
145 |
97 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,923 |
4,740 |
$0.00 |
| D9987 |
|
39 |
38 |
$0.00 |
| D9986 |
|
79 |
79 |
$0.00 |