| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,430 |
1,144 |
$684K |
| D1120 |
Prophylaxis - child |
23,204 |
20,506 |
$630K |
| D1206 |
Topical application of fluoride varnish |
21,781 |
19,281 |
$496K |
| D0120 |
Periodic oral evaluation - established patient |
16,136 |
15,124 |
$433K |
| D1351 |
Sealant - per tooth |
6,386 |
1,231 |
$176K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,625 |
842 |
$174K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,404 |
3,894 |
$158K |
| D0272 |
Bitewings - two radiographic images |
9,105 |
8,201 |
$154K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,549 |
519 |
$133K |
| D0330 |
Panoramic radiographic image |
2,792 |
2,600 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,515 |
727 |
$113K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,691 |
2,374 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,043 |
550 |
$84K |
| D9420 |
|
232 |
228 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
461 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
196 |
$14K |
| D9310 |
|
283 |
259 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
991 |
908 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
510 |
454 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
70 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$674.22 |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$473.66 |