| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,734 |
1,194 |
$1.05M |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,421 |
956 |
$282K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,577 |
480 |
$107K |
| D9420 |
|
1,351 |
1,342 |
$102K |
| D2330 |
|
493 |
165 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,323 |
1,320 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
119 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
420 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,258 |
1,255 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
604 |
604 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,257 |
1,251 |
$12K |
| D2335 |
|
72 |
33 |
$9K |
| D1120 |
Prophylaxis - child |
348 |
346 |
$9K |
| D1206 |
Topical application of fluoride varnish |
295 |
295 |
$5K |
| D1351 |
Sealant - per tooth |
36 |
15 |
$871.56 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
62 |
$609.64 |