| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,769 |
793 |
$844K |
| D1120 |
Prophylaxis - child |
13,577 |
13,393 |
$563K |
| D1206 |
Topical application of fluoride varnish |
20,358 |
19,982 |
$478K |
| D0120 |
Periodic oral evaluation - established patient |
16,005 |
15,765 |
$464K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,698 |
768 |
$424K |
| D1110 |
Prophylaxis - adult |
6,330 |
6,230 |
$351K |
| D0274 |
Bitewings - four radiographic images |
8,248 |
8,075 |
$319K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,364 |
911 |
$314K |
| D0330 |
Panoramic radiographic image |
4,688 |
4,582 |
$292K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,198 |
5,094 |
$197K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,704 |
612 |
$182K |
| D9248 |
|
1,063 |
1,009 |
$156K |
| D1351 |
Sealant - per tooth |
3,148 |
416 |
$114K |
| D0272 |
Bitewings - two radiographic images |
3,948 |
3,889 |
$109K |
| D2934 |
|
617 |
148 |
$102K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,629 |
2,510 |
$84K |
| D0140 |
Limited oral evaluation - problem focused |
1,583 |
1,511 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
2,526 |
2,434 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
236 |
75 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
32 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
56 |
$9K |
| D7961 |
|
19 |
13 |
$4K |
| D1510 |
|
18 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
184 |
122 |
$2K |
| D1999 |
|
13,695 |
13,154 |
$10.00 |