| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,606 |
709 |
$313K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,551 |
808 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
922 |
566 |
$118K |
| D1120 |
Prophylaxis - child |
1,654 |
1,654 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,013 |
1,012 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
580 |
393 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,635 |
1,620 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,602 |
1,600 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
2,150 |
2,116 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
644 |
636 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
891 |
889 |
$35K |
| D0240 |
|
1,265 |
725 |
$26K |
| D9248 |
|
191 |
181 |
$25K |
| D1351 |
Sealant - per tooth |
553 |
250 |
$19K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
92 |
65 |
$12K |
| D9310 |
|
103 |
103 |
$10K |
| D0272 |
Bitewings - two radiographic images |
308 |
307 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
162 |
162 |
$7K |
| D1510 |
|
31 |
25 |
$7K |