| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,582 |
1,240 |
$682K |
| D1120 |
Prophylaxis - child |
4,673 |
4,673 |
$192K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,067 |
817 |
$182K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,912 |
1,131 |
$176K |
| D1206 |
Topical application of fluoride varnish |
4,973 |
4,973 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
3,690 |
3,690 |
$121K |
| D9310 |
|
1,078 |
1,077 |
$77K |
| D1510 |
|
399 |
248 |
$76K |
| D2390 |
|
333 |
162 |
$66K |
| D0272 |
Bitewings - two radiographic images |
3,068 |
3,067 |
$57K |
| D0240 |
|
1,883 |
996 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
303 |
191 |
$38K |
| D1351 |
Sealant - per tooth |
1,177 |
432 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
488 |
483 |
$28K |
| D0274 |
Bitewings - four radiographic images |
476 |
476 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
110 |
71 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
774 |
768 |
$14K |
| D1110 |
Prophylaxis - adult |
247 |
247 |
$14K |
| D7111 |
|
159 |
91 |
$11K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$7K |
| D9920 |
|
89 |
82 |
$5K |
| D9420 |
|
35 |
35 |
$4K |
| D1354 |
|
133 |
68 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
31 |
$704.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$646.00 |
| D3120 |
|
49 |
26 |
$0.00 |