| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,015 |
636 |
$423K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,446 |
905 |
$190K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,148 |
546 |
$111K |
| D1120 |
Prophylaxis - child |
1,980 |
1,975 |
$95K |
| D9310 |
|
1,077 |
1,076 |
$85K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
632 |
272 |
$80K |
| D1206 |
Topical application of fluoride varnish |
2,322 |
2,307 |
$76K |
| D1351 |
Sealant - per tooth |
2,124 |
613 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,137 |
1,698 |
$70K |
| D2940 |
|
857 |
344 |
$63K |
| D1354 |
|
1,972 |
492 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
596 |
410 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
362 |
309 |
$60K |
| D0240 |
|
2,402 |
1,229 |
$51K |
| D9420 |
|
253 |
246 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
600 |
598 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
1,872 |
1,848 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
494 |
490 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
841 |
837 |
$32K |
| D2330 |
|
198 |
113 |
$18K |
| D2332 |
|
124 |
61 |
$16K |
| D0330 |
Panoramic radiographic image |
133 |
132 |
$9K |
| D2390 |
|
37 |
15 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
634 |
234 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
98 |
98 |
$4K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$1K |