| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,050 |
921 |
$565K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,489 |
1,005 |
$194K |
| D1120 |
Prophylaxis - child |
2,134 |
2,127 |
$109K |
| D1206 |
Topical application of fluoride varnish |
2,376 |
2,374 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
870 |
415 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
1,738 |
1,736 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
585 |
289 |
$38K |
| D9310 |
|
318 |
318 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,448 |
1,445 |
$29K |
| D0240 |
|
833 |
728 |
$29K |
| D7962 |
|
55 |
55 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
231 |
$6K |
| D2140 |
|
34 |
25 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$655.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$521.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$433.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$208.66 |