| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,137 |
306 |
$226K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
497 |
241 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
553 |
261 |
$48K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
373 |
181 |
$48K |
| D1120 |
Prophylaxis - child |
1,024 |
1,024 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
404 |
214 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,086 |
1,085 |
$31K |
| D2390 |
|
145 |
44 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
376 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
640 |
640 |
$21K |
| D1515 |
|
59 |
48 |
$20K |
| D1351 |
Sealant - per tooth |
487 |
171 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,092 |
583 |
$15K |
| D9420 |
|
96 |
96 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
711 |
705 |
$13K |
| D0240 |
|
614 |
309 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
185 |
$12K |
| D0272 |
Bitewings - two radiographic images |
415 |
415 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
83 |
$7K |
| D2330 |
|
75 |
46 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
73 |
73 |
$3K |
| D9920 |
|
18 |
16 |
$1K |