| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,771 |
617 |
$340K |
| D1120 |
Prophylaxis - child |
3,886 |
3,516 |
$115K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,222 |
518 |
$88K |
| D1206 |
Topical application of fluoride varnish |
3,561 |
3,214 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,438 |
1,275 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
692 |
422 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,791 |
1,663 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
750 |
673 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,609 |
1,432 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,227 |
988 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,674 |
1,443 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
136 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,865 |
829 |
$17K |
| D9420 |
|
54 |
46 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
228 |
212 |
$9K |
| D1351 |
Sealant - per tooth |
286 |
82 |
$7K |
| D0330 |
Panoramic radiographic image |
119 |
116 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
50 |
24 |
$4K |
| D9310 |
|
75 |
69 |
$3K |
| D9248 |
|
96 |
87 |
$3K |
| D0274 |
Bitewings - four radiographic images |
44 |
43 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$1K |