| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,569 |
849 |
$310K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,171 |
1,433 |
$265K |
| D1120 |
Prophylaxis - child |
5,575 |
5,569 |
$230K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,556 |
853 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
4,694 |
4,690 |
$158K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,854 |
4,847 |
$136K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,575 |
936 |
$135K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,375 |
986 |
$127K |
| D0210 |
Intraoral - complete series of radiographic images |
787 |
787 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,792 |
1,464 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
2,581 |
2,553 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,841 |
1,838 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
722 |
718 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
741 |
741 |
$43K |
| D1510 |
|
177 |
155 |
$38K |
| D1110 |
Prophylaxis - adult |
609 |
609 |
$31K |
| D1206 |
Topical application of fluoride varnish |
917 |
917 |
$26K |
| D2330 |
|
167 |
103 |
$15K |
| D9420 |
|
102 |
102 |
$14K |
| D0274 |
Bitewings - four radiographic images |
348 |
348 |
$14K |
| D1351 |
Sealant - per tooth |
422 |
156 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
174 |
174 |
$7K |
| D1354 |
|
53 |
15 |
$2K |