| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,258 |
851 |
$498K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,098 |
1,102 |
$349K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
560 |
234 |
$31K |
| D1120 |
Prophylaxis - child |
1,352 |
1,283 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,065 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,124 |
1,052 |
$18K |
| D1351 |
Sealant - per tooth |
742 |
244 |
$18K |
| D0272 |
Bitewings - two radiographic images |
995 |
956 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
335 |
322 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,019 |
306 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
102 |
65 |
$6K |
| D2330 |
|
110 |
43 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
463 |
459 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
74 |
$5K |
| D0240 |
|
286 |
205 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
608 |
567 |
$4K |
| D1110 |
Prophylaxis - adult |
70 |
69 |
$2K |
| D2331 |
|
21 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
66 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$451.60 |
| D1330 |
|
36 |
25 |
$0.00 |
| D1310 |
|
36 |
25 |
$0.00 |