| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,810 |
993 |
$976K |
| D1120 |
Prophylaxis - child |
27,418 |
25,291 |
$870K |
| D1208 |
Topical application of fluoride, excluding varnish |
38,440 |
35,253 |
$763K |
| D0120 |
Periodic oral evaluation - established patient |
34,853 |
32,064 |
$721K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
6,806 |
1,003 |
$681K |
| D1351 |
Sealant - per tooth |
25,546 |
4,581 |
$635K |
| D0330 |
Panoramic radiographic image |
7,189 |
6,555 |
$408K |
| D1110 |
Prophylaxis - adult |
9,323 |
8,441 |
$398K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,327 |
2,789 |
$315K |
| D0272 |
Bitewings - two radiographic images |
14,043 |
12,792 |
$307K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,104 |
1,783 |
$232K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,528 |
5,040 |
$184K |
| D2394 |
|
1,855 |
835 |
$150K |
| D0140 |
Limited oral evaluation - problem focused |
4,033 |
3,575 |
$132K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,213 |
444 |
$105K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,160 |
743 |
$51K |
| D9920 |
|
1,070 |
941 |
$46K |
| D0274 |
Bitewings - four radiographic images |
793 |
770 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,322 |
2,039 |
$27K |
| D2332 |
|
163 |
49 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,500 |
1,164 |
$15K |
| D0251 |
|
317 |
306 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$71.00 |
| D1999 |
|
334 |
283 |
$0.00 |