| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,629 |
421 |
$324K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
539 |
203 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
756 |
273 |
$66K |
| D1120 |
Prophylaxis - child |
1,414 |
1,413 |
$57K |
| D2933 |
|
228 |
67 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,526 |
1,524 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
160 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,010 |
1,009 |
$32K |
| D9420 |
|
216 |
214 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
340 |
339 |
$21K |
| D1351 |
Sealant - per tooth |
599 |
211 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
205 |
139 |
$18K |
| D0240 |
|
825 |
483 |
$17K |
| D0272 |
Bitewings - two radiographic images |
577 |
577 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
163 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
412 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
569 |
224 |
$8K |
| D9310 |
|
84 |
84 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
116 |
115 |
$5K |
| D1510 |
|
19 |
13 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
53 |
$4K |
| D2330 |
|
19 |
13 |
$2K |
| D9248 |
|
26 |
25 |
$1K |