| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,979 |
1,673 |
$771K |
| D9248 |
|
854 |
785 |
$105K |
| D9310 |
|
1,685 |
1,635 |
$81K |
| D2934 |
|
477 |
129 |
$70K |
| D1120 |
Prophylaxis - child |
2,684 |
2,639 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,040 |
495 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,573 |
2,523 |
$46K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
470 |
239 |
$40K |
| D1206 |
Topical application of fluoride varnish |
2,714 |
2,665 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,600 |
2,527 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,895 |
1,852 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
157 |
$25K |
| D0240 |
|
1,005 |
996 |
$17K |
| D1351 |
Sealant - per tooth |
484 |
187 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
198 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
274 |
266 |
$6K |
| D0330 |
Panoramic radiographic image |
129 |
125 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
12 |
$144.78 |