| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,714 |
553 |
$303K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
985 |
441 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
890 |
470 |
$72K |
| D2390 |
|
309 |
123 |
$64K |
| D1120 |
Prophylaxis - child |
1,612 |
1,606 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,844 |
1,095 |
$61K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
382 |
183 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
502 |
267 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,594 |
1,586 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
755 |
750 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
877 |
873 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,372 |
1,358 |
$24K |
| D1510 |
|
138 |
107 |
$24K |
| D1351 |
Sealant - per tooth |
512 |
163 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
259 |
$14K |
| D9248 |
|
86 |
85 |
$5K |
| D3230 |
|
25 |
12 |
$4K |
| D2330 |
|
36 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$3K |
| D2332 |
|
23 |
12 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$2K |