| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,196 |
254 |
$123K |
| D7140 |
Extraction, erupted tooth or exposed root |
769 |
211 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
716 |
205 |
$46K |
| D2390 |
|
144 |
39 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
304 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
39 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
121 |
49 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
348 |
329 |
$6K |
| D0272 |
Bitewings - two radiographic images |
326 |
325 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
245 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
29 |
$5K |
| D9920 |
|
34 |
33 |
$4K |
| D1206 |
Topical application of fluoride varnish |
232 |
231 |
$4K |
| D9110 |
|
124 |
124 |
$4K |
| D9430 |
|
15 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
346 |
$3K |
| D1330 |
|
175 |
175 |
$2K |
| D1310 |
|
174 |
174 |
$2K |
| D1351 |
Sealant - per tooth |
83 |
27 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$1K |
| D9995 |
|
310 |
300 |
$0.55 |
| T1015 |
Clinic visit/encounter, all-inclusive |
15 |
14 |
$0.00 |