| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,936 |
1,173 |
$636K |
| D1120 |
Prophylaxis - child |
18,100 |
15,098 |
$471K |
| D0120 |
Periodic oral evaluation - established patient |
16,710 |
13,776 |
$373K |
| D1206 |
Topical application of fluoride varnish |
13,994 |
12,124 |
$305K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,816 |
1,158 |
$175K |
| D0272 |
Bitewings - two radiographic images |
9,291 |
7,277 |
$152K |
| D0330 |
Panoramic radiographic image |
2,900 |
2,432 |
$139K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,289 |
3,297 |
$110K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,372 |
653 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,620 |
2,280 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,076 |
753 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,998 |
2,826 |
$47K |
| D1351 |
Sealant - per tooth |
1,439 |
311 |
$35K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
367 |
209 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
231 |
206 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
311 |
273 |
$4K |
| D0274 |
Bitewings - four radiographic images |
61 |
57 |
$2K |