| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
609 |
379 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
763 |
464 |
$97K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
558 |
356 |
$71K |
| D7140 |
Extraction, erupted tooth or exposed root |
577 |
347 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,448 |
1,444 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
222 |
$29K |
| D1120 |
Prophylaxis - child |
872 |
867 |
$27K |
| D9920 |
|
375 |
372 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
934 |
929 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
140 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
128 |
$8K |
| D1351 |
Sealant - per tooth |
196 |
77 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
444 |
196 |
$6K |
| D0330 |
Panoramic radiographic image |
77 |
76 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
296 |
296 |
$5K |
| D0272 |
Bitewings - two radiographic images |
113 |
112 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
30 |
30 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$466.29 |