| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,368 |
1,714 |
$858K |
| D1120 |
Prophylaxis - child |
17,668 |
17,656 |
$753K |
| D1206 |
Topical application of fluoride varnish |
17,775 |
17,753 |
$502K |
| D0120 |
Periodic oral evaluation - established patient |
13,978 |
13,972 |
$479K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,030 |
2,052 |
$382K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,788 |
1,036 |
$230K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,528 |
1,413 |
$222K |
| D0272 |
Bitewings - two radiographic images |
8,079 |
8,064 |
$205K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,036 |
1,453 |
$193K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,720 |
2,715 |
$164K |
| D1351 |
Sealant - per tooth |
3,706 |
1,307 |
$120K |
| D0140 |
Limited oral evaluation - problem focused |
1,963 |
1,920 |
$118K |
| D1354 |
|
3,391 |
1,481 |
$93K |
| D0240 |
|
4,466 |
2,456 |
$92K |
| D0220 |
Intraoral - periapical first radiographic image |
3,478 |
3,418 |
$64K |
| D0330 |
Panoramic radiographic image |
690 |
689 |
$51K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,217 |
1,214 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,526 |
972 |
$20K |
| D9420 |
|
132 |
131 |
$17K |
| D0274 |
Bitewings - four radiographic images |
213 |
213 |
$9K |
| D9310 |
|
102 |
102 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,811 |
3,690 |
$0.00 |
| D1999 |
|
34 |
33 |
$0.00 |