| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,663 |
1,250 |
$489K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,034 |
1,465 |
$352K |
| D1120 |
Prophylaxis - child |
6,094 |
6,093 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
6,201 |
6,200 |
$199K |
| D1206 |
Topical application of fluoride varnish |
6,380 |
6,379 |
$168K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,708 |
913 |
$138K |
| D0140 |
Limited oral evaluation - problem focused |
1,804 |
1,793 |
$106K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,100 |
750 |
$94K |
| D0272 |
Bitewings - two radiographic images |
2,618 |
2,618 |
$63K |
| D1351 |
Sealant - per tooth |
2,024 |
799 |
$61K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
366 |
247 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
1,774 |
1,757 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,217 |
1,011 |
$29K |
| D1110 |
Prophylaxis - adult |
337 |
337 |
$16K |
| D0330 |
Panoramic radiographic image |
174 |
173 |
$12K |
| D0274 |
Bitewings - four radiographic images |
272 |
272 |
$9K |
| D9248 |
|
96 |
94 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$3K |