| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,897 |
1,575 |
$745K |
| D1120 |
Prophylaxis - child |
8,761 |
8,745 |
$353K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,731 |
1,433 |
$347K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,803 |
1,526 |
$234K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,411 |
4,896 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
5,838 |
5,829 |
$178K |
| D1206 |
Topical application of fluoride varnish |
5,403 |
5,395 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,599 |
2,596 |
$128K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
892 |
543 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,125 |
747 |
$108K |
| D0220 |
Intraoral - periapical first radiographic image |
5,886 |
5,840 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,456 |
3,449 |
$80K |
| D1351 |
Sealant - per tooth |
2,330 |
708 |
$67K |
| D1510 |
|
217 |
172 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
608 |
603 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,072 |
1,071 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
544 |
544 |
$19K |
| D9310 |
|
222 |
221 |
$13K |
| D0330 |
Panoramic radiographic image |
124 |
123 |
$7K |
| D2330 |
|
40 |
27 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
78 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$644.66 |