| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,975 |
1,740 |
$707K |
| D1120 |
Prophylaxis - child |
14,916 |
14,674 |
$659K |
| D1206 |
Topical application of fluoride varnish |
14,845 |
14,606 |
$512K |
| D1351 |
Sealant - per tooth |
11,656 |
2,537 |
$266K |
| D0120 |
Periodic oral evaluation - established patient |
9,975 |
9,788 |
$245K |
| D0272 |
Bitewings - two radiographic images |
12,274 |
12,063 |
$214K |
| D9248 |
|
1,922 |
1,894 |
$174K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,830 |
4,766 |
$156K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,894 |
1,452 |
$153K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,513 |
1,617 |
$137K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,258 |
885 |
$119K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,767 |
970 |
$106K |
| D0220 |
Intraoral - periapical first radiographic image |
6,174 |
6,063 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,576 |
7,063 |
$56K |
| D2933 |
|
440 |
92 |
$48K |
| D3120 |
|
2,531 |
889 |
$45K |
| D9420 |
|
1,031 |
1,000 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
1,053 |
1,031 |
$34K |
| D1510 |
|
314 |
254 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,449 |
3,405 |
$30K |
| D1354 |
|
2,441 |
778 |
$29K |
| D9999 |
Unspecified adjunctive procedure, by report |
1,081 |
1,081 |
$27K |
| D0999 |
Unspecified diagnostic procedure, by report |
773 |
773 |
$23K |
| D0603 |
|
2,807 |
2,772 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
290 |
176 |
$12K |
| D0330 |
Panoramic radiographic image |
175 |
174 |
$7K |
| D9310 |
|
169 |
168 |
$7K |
| D0274 |
Bitewings - four radiographic images |
181 |
180 |
$4K |
| D1353 |
|
237 |
109 |
$3K |
| D1999 |
|
221 |
221 |
$3K |
| D0601 |
|
710 |
705 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
16 |
$2K |
| D0602 |
|
538 |
535 |
$2K |