| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,332 |
868 |
$611K |
| D9420 |
|
789 |
780 |
$176K |
| D1120 |
Prophylaxis - child |
6,569 |
6,533 |
$163K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,397 |
758 |
$152K |
| D1206 |
Topical application of fluoride varnish |
9,275 |
9,170 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
6,785 |
6,767 |
$122K |
| D1351 |
Sealant - per tooth |
3,379 |
845 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
978 |
514 |
$76K |
| D0272 |
Bitewings - two radiographic images |
3,953 |
3,941 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,347 |
1,323 |
$63K |
| D1110 |
Prophylaxis - adult |
1,356 |
1,352 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
835 |
832 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
368 |
194 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,423 |
1,412 |
$33K |
| D0240 |
|
1,522 |
1,140 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
905 |
868 |
$11K |
| D2934 |
|
46 |
13 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
104 |
$10K |
| D1354 |
|
702 |
285 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
234 |
157 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |