| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,587 |
730 |
$490K |
| D9420 |
|
1,043 |
1,028 |
$116K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,037 |
349 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,150 |
371 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
990 |
978 |
$40K |
| D0240 |
|
2,469 |
1,226 |
$37K |
| D1120 |
Prophylaxis - child |
1,256 |
1,238 |
$30K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
281 |
133 |
$25K |
| D1351 |
Sealant - per tooth |
1,774 |
559 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,307 |
1,288 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,149 |
1,135 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
80 |
$13K |
| D0330 |
Panoramic radiographic image |
182 |
180 |
$8K |
| D2331 |
|
73 |
43 |
$6K |
| D2332 |
|
59 |
28 |
$5K |
| D2335 |
|
42 |
13 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
12 |
$2K |
| D2330 |
|
33 |
16 |
$2K |
| D2140 |
|
28 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$155.98 |
| D3120 |
|
169 |
97 |
$0.00 |
| D0191 |
|
61 |
60 |
$0.00 |