| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,333 |
1,386 |
$414K |
| D2933 |
|
1,385 |
544 |
$199K |
| D1120 |
Prophylaxis - child |
4,726 |
4,592 |
$90K |
| D1510 |
|
788 |
533 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,385 |
793 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,925 |
4,796 |
$72K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,110 |
499 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
3,456 |
3,370 |
$56K |
| D0240 |
|
6,116 |
2,386 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,932 |
1,854 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,702 |
2,811 |
$41K |
| D1351 |
Sealant - per tooth |
1,942 |
549 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
700 |
434 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,709 |
1,517 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
701 |
431 |
$34K |
| D0330 |
Panoramic radiographic image |
576 |
555 |
$25K |
| D0274 |
Bitewings - four radiographic images |
848 |
825 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,395 |
3,246 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,154 |
1,121 |
$11K |
| D1110 |
Prophylaxis - adult |
302 |
289 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
416 |
393 |
$9K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$30.00 |