| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,480 |
1,731 |
$1.03M |
| D1120 |
Prophylaxis - child |
16,122 |
14,521 |
$436K |
| D1206 |
Topical application of fluoride varnish |
14,540 |
13,071 |
$316K |
| D0120 |
Periodic oral evaluation - established patient |
11,330 |
10,737 |
$300K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,647 |
1,465 |
$201K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,307 |
1,465 |
$196K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,309 |
923 |
$157K |
| D0140 |
Limited oral evaluation - problem focused |
3,557 |
3,158 |
$134K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,524 |
2,990 |
$117K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,181 |
524 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,959 |
3,040 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
4,535 |
4,065 |
$55K |
| D0330 |
Panoramic radiographic image |
968 |
923 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,307 |
1,218 |
$24K |
| D0272 |
Bitewings - two radiographic images |
725 |
703 |
$15K |
| D2330 |
|
119 |
65 |
$9K |
| D1510 |
|
18 |
15 |
$4K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$195.00 |