| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
10,681 |
2,504 |
$2.04M |
| D1120 |
Prophylaxis - child |
8,621 |
8,274 |
$429K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,088 |
1,563 |
$382K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,431 |
1,090 |
$245K |
| D1206 |
Topical application of fluoride varnish |
9,118 |
8,735 |
$226K |
| D0120 |
Periodic oral evaluation - established patient |
6,753 |
6,447 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,721 |
814 |
$182K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,343 |
2,277 |
$124K |
| D2335 |
|
747 |
271 |
$121K |
| D9110 |
|
1,510 |
1,444 |
$107K |
| D0140 |
Limited oral evaluation - problem focused |
2,382 |
2,245 |
$105K |
| D0274 |
Bitewings - four radiographic images |
1,835 |
1,773 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
2,838 |
2,706 |
$53K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,573 |
2,267 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,738 |
2,513 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,247 |
1,186 |
$35K |
| D1110 |
Prophylaxis - adult |
379 |
350 |
$24K |
| D2332 |
|
163 |
55 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
24 |
$6K |
| D1351 |
Sealant - per tooth |
90 |
26 |
$4K |
| D2330 |
|
26 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$440.00 |
| D0240 |
|
74 |
35 |
$135.00 |