| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,305 |
1,020 |
$589K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,999 |
919 |
$162K |
| D1120 |
Prophylaxis - child |
2,829 |
2,803 |
$102K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,127 |
2,006 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,894 |
1,866 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
771 |
459 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
547 |
318 |
$65K |
| D1206 |
Topical application of fluoride varnish |
2,323 |
2,298 |
$54K |
| D2390 |
|
281 |
108 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
2,393 |
2,353 |
$40K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
332 |
221 |
$40K |
| D1351 |
Sealant - per tooth |
1,341 |
440 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
578 |
570 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
846 |
839 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
565 |
564 |
$12K |
| D2330 |
|
137 |
92 |
$11K |
| D2934 |
|
44 |
12 |
$11K |
| D0330 |
Panoramic radiographic image |
173 |
172 |
$9K |
| D9248 |
|
132 |
128 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
224 |
224 |
$6K |
| D1510 |
|
27 |
26 |
$5K |
| D0272 |
Bitewings - two radiographic images |
187 |
187 |
$4K |
| D1110 |
Prophylaxis - adult |
84 |
82 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
42 |
$2K |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$614.00 |