| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,144 |
614 |
$291K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,939 |
551 |
$163K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,470 |
542 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,284 |
457 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
626 |
312 |
$45K |
| D2934 |
|
177 |
72 |
$24K |
| D1510 |
|
139 |
96 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
862 |
549 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
717 |
695 |
$8K |
| D1351 |
Sealant - per tooth |
297 |
106 |
$7K |
| D1120 |
Prophylaxis - child |
217 |
208 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
169 |
162 |
$5K |
| D0272 |
Bitewings - two radiographic images |
278 |
268 |
$5K |
| D2331 |
|
51 |
25 |
$4K |
| D1206 |
Topical application of fluoride varnish |
247 |
237 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
24 |
$3K |
| D2330 |
|
47 |
25 |
$3K |
| D2332 |
|
26 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
46 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$437.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$291.00 |