| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,604 |
1,181 |
$522K |
| D1120 |
Prophylaxis - child |
5,021 |
5,017 |
$215K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,628 |
1,130 |
$210K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,244 |
663 |
$162K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,479 |
1,087 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,666 |
3,664 |
$126K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,094 |
619 |
$108K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,553 |
3,551 |
$87K |
| D0220 |
Intraoral - periapical first radiographic image |
3,885 |
3,827 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,112 |
1,112 |
$69K |
| D0272 |
Bitewings - two radiographic images |
2,765 |
2,756 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,278 |
3,336 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
762 |
751 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,470 |
1,466 |
$45K |
| D1351 |
Sealant - per tooth |
1,221 |
525 |
$39K |
| D1510 |
|
119 |
94 |
$25K |
| D1354 |
|
741 |
248 |
$20K |
| D0145 |
Oral evaluation for a patient under three years of age |
446 |
445 |
$18K |
| D1110 |
Prophylaxis - adult |
205 |
205 |
$10K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$2K |