| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,104 |
572 |
$364K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
849 |
303 |
$83K |
| D9420 |
|
967 |
722 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
749 |
749 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
690 |
230 |
$38K |
| D1310 |
|
795 |
795 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
375 |
150 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,472 |
894 |
$21K |
| D3230 |
|
164 |
58 |
$16K |
| D1120 |
Prophylaxis - child |
358 |
358 |
$15K |
| D0350 |
|
1,029 |
491 |
$13K |
| D2330 |
|
172 |
95 |
$13K |
| D0603 |
|
1,075 |
1,074 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
139 |
54 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
83 |
$9K |
| D0272 |
Bitewings - two radiographic images |
762 |
762 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$8K |
| D1206 |
Topical application of fluoride varnish |
314 |
314 |
$7K |
| D1351 |
Sealant - per tooth |
167 |
63 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
66 |
66 |
$4K |
| D1510 |
|
22 |
14 |
$4K |
| D2140 |
|
58 |
29 |
$3K |
| D2332 |
|
17 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D9920 |
|
13 |
13 |
$840.00 |
| D9610 |
|
76 |
41 |
$598.50 |
| D0140 |
Limited oral evaluation - problem focused |
199 |
198 |
$0.00 |