| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,596 |
436 |
$313K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
912 |
346 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
831 |
434 |
$89K |
| D9420 |
|
509 |
509 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
399 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
642 |
302 |
$53K |
| D2390 |
|
190 |
65 |
$39K |
| D2330 |
|
445 |
226 |
$37K |
| D1120 |
Prophylaxis - child |
677 |
677 |
$24K |
| D2331 |
|
221 |
106 |
$23K |
| D0240 |
|
928 |
474 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,368 |
459 |
$18K |
| D1206 |
Topical application of fluoride varnish |
726 |
726 |
$17K |
| D0272 |
Bitewings - two radiographic images |
549 |
549 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
466 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
182 |
$4K |
| D2140 |
|
18 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$845.00 |