| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
960 |
366 |
$142K |
| D7140 |
Extraction, erupted tooth or exposed root |
873 |
281 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
794 |
284 |
$47K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
641 |
209 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
262 |
133 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
187 |
$11K |
| D9110 |
|
299 |
299 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
40 |
$7K |
| D1206 |
Topical application of fluoride varnish |
398 |
396 |
$7K |
| D0272 |
Bitewings - two radiographic images |
388 |
387 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
231 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
281 |
277 |
$6K |
| D2390 |
|
40 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
533 |
531 |
$4K |
| D1351 |
Sealant - per tooth |
147 |
55 |
$3K |
| D9920 |
|
16 |
16 |
$2K |
| D1310 |
|
263 |
257 |
$2K |
| D1330 |
|
262 |
256 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$222.48 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$132.00 |
| D9995 |
|
175 |
174 |
$46.59 |
| D0706 |
|
21 |
20 |
$0.00 |