| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,209 |
997 |
$465K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,781 |
850 |
$146K |
| D1120 |
Prophylaxis - child |
4,519 |
4,482 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,398 |
866 |
$105K |
| D1206 |
Topical application of fluoride varnish |
4,465 |
4,429 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,894 |
2,864 |
$80K |
| D1351 |
Sealant - per tooth |
2,240 |
827 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,835 |
1,829 |
$63K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,495 |
1,427 |
$62K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
570 |
357 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
620 |
448 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,946 |
2,919 |
$43K |
| D2335 |
|
237 |
99 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
909 |
900 |
$29K |
| D0240 |
|
1,365 |
638 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,433 |
1,413 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,028 |
982 |
$6K |
| D1510 |
|
33 |
25 |
$4K |
| D1354 |
|
133 |
61 |
$3K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |