| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,137 |
1,480 |
$949K |
| D1120 |
Prophylaxis - child |
10,150 |
10,149 |
$366K |
| D1206 |
Topical application of fluoride varnish |
11,092 |
11,087 |
$252K |
| D0120 |
Periodic oral evaluation - established patient |
8,665 |
8,662 |
$251K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,890 |
1,407 |
$234K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,055 |
1,424 |
$232K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,460 |
1,638 |
$210K |
| D1351 |
Sealant - per tooth |
4,088 |
1,579 |
$114K |
| D0272 |
Bitewings - two radiographic images |
6,142 |
6,139 |
$94K |
| D1354 |
|
2,936 |
1,246 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
3,794 |
3,750 |
$63K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
496 |
287 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
981 |
976 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,506 |
1,718 |
$42K |
| D0240 |
|
2,196 |
1,212 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
750 |
750 |
$40K |
| D9310 |
|
427 |
427 |
$28K |
| D0330 |
Panoramic radiographic image |
399 |
399 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
272 |
272 |
$17K |
| D2330 |
|
128 |
76 |
$11K |
| D1110 |
Prophylaxis - adult |
160 |
159 |
$7K |
| D0274 |
Bitewings - four radiographic images |
224 |
223 |
$6K |
| D2940 |
|
39 |
26 |
$3K |
| D3120 |
|
156 |
117 |
$0.00 |
| D0603 |
|
2,944 |
2,943 |
$0.00 |
| D0601 |
|
26 |
26 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |