| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,137 |
1,465 |
$402K |
| D1120 |
Prophylaxis - child |
12,828 |
12,243 |
$310K |
| D1206 |
Topical application of fluoride varnish |
14,825 |
14,190 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
12,716 |
12,216 |
$213K |
| D1110 |
Prophylaxis - adult |
2,527 |
2,432 |
$85K |
| D0272 |
Bitewings - two radiographic images |
5,613 |
5,345 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,378 |
653 |
$69K |
| D1351 |
Sealant - per tooth |
3,623 |
788 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
874 |
590 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,001 |
1,887 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,406 |
2,257 |
$44K |
| D0330 |
Panoramic radiographic image |
1,368 |
1,297 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
713 |
525 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
3,062 |
2,913 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
783 |
756 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
760 |
697 |
$15K |
| D0274 |
Bitewings - four radiographic images |
715 |
685 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,148 |
724 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
162 |
93 |
$9K |
| D9310 |
|
332 |
326 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
183 |
$8K |
| D9420 |
|
160 |
156 |
$6K |
| D2330 |
|
17 |
12 |
$1K |