| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,683 |
457 |
$701K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,501 |
410 |
$275K |
| D9420 |
|
565 |
555 |
$170K |
| D3120 |
|
926 |
316 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
812 |
781 |
$63K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
218 |
119 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
97 |
$43K |
| D1120 |
Prophylaxis - child |
631 |
630 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
754 |
456 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
348 |
$31K |
| D0240 |
|
629 |
492 |
$30K |
| D1206 |
Topical application of fluoride varnish |
667 |
665 |
$27K |
| D0272 |
Bitewings - two radiographic images |
631 |
628 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
723 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
39 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
192 |
192 |
$9K |
| D2330 |
|
37 |
24 |
$6K |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$1K |
| D0171 |
|
14 |
14 |
$14.00 |