| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,267 |
623 |
$325K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,904 |
516 |
$125K |
| D2390 |
|
623 |
186 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
538 |
207 |
$28K |
| D1510 |
|
220 |
126 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
237 |
143 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
884 |
438 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
205 |
$11K |
| D1120 |
Prophylaxis - child |
382 |
382 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
226 |
226 |
$10K |
| D1206 |
Topical application of fluoride varnish |
543 |
543 |
$10K |
| D1351 |
Sealant - per tooth |
390 |
123 |
$10K |
| D2330 |
|
154 |
84 |
$8K |
| D2931 |
|
51 |
15 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
250 |
$5K |
| D0272 |
Bitewings - two radiographic images |
313 |
311 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
25 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
446 |
$4K |
| D1330 |
|
171 |
170 |
$2K |
| D1310 |
|
171 |
170 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$1K |
| D9995 |
|
201 |
201 |
$0.00 |