| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,403 |
867 |
$465K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,572 |
599 |
$134K |
| D1120 |
Prophylaxis - child |
2,702 |
2,702 |
$111K |
| D2390 |
|
458 |
200 |
$90K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
931 |
545 |
$88K |
| D1206 |
Topical application of fluoride varnish |
2,692 |
2,692 |
$75K |
| D9420 |
|
506 |
506 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,784 |
1,784 |
$60K |
| D9310 |
|
653 |
653 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,602 |
1,602 |
$38K |
| D0240 |
|
1,587 |
821 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
220 |
126 |
$27K |
| D1510 |
|
138 |
90 |
$27K |
| D2330 |
|
131 |
92 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
512 |
511 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
152 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
44 |
$7K |
| D1351 |
Sealant - per tooth |
107 |
39 |
$3K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$2K |
| D1354 |
|
34 |
16 |
$930.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
41 |
$888.98 |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$635.79 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$528.00 |
| D3120 |
|
15 |
12 |
$0.00 |