| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,409 |
2,152 |
$778K |
| D2934 |
|
2,321 |
547 |
$289K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,480 |
1,323 |
$208K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,362 |
1,134 |
$186K |
| D1120 |
Prophylaxis - child |
5,234 |
5,234 |
$169K |
| D9248 |
|
2,271 |
2,168 |
$142K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,222 |
815 |
$121K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,120 |
2,969 |
$95K |
| D0140 |
Limited oral evaluation - problem focused |
2,504 |
2,487 |
$93K |
| D1206 |
Topical application of fluoride varnish |
5,973 |
5,973 |
$90K |
| D0272 |
Bitewings - two radiographic images |
4,595 |
4,595 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,034 |
733 |
$79K |
| D9420 |
|
888 |
888 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
3,418 |
3,418 |
$71K |
| D1351 |
Sealant - per tooth |
2,139 |
586 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
4,721 |
4,684 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,248 |
1,248 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,726 |
3,927 |
$44K |
| D1110 |
Prophylaxis - adult |
902 |
902 |
$41K |
| D2330 |
|
500 |
238 |
$33K |
| D9920 |
|
390 |
388 |
$20K |
| D0330 |
Panoramic radiographic image |
391 |
391 |
$18K |
| D0274 |
Bitewings - four radiographic images |
668 |
668 |
$16K |
| D1510 |
|
95 |
82 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
452 |
452 |
$16K |
| D2932 |
|
44 |
12 |
$7K |
| D9992 |
|
35 |
35 |
$855.34 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$405.00 |