| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,897 |
1,472 |
$543K |
| D1120 |
Prophylaxis - child |
10,299 |
10,291 |
$375K |
| D0120 |
Periodic oral evaluation - established patient |
10,286 |
10,278 |
$290K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,823 |
1,206 |
$274K |
| D1351 |
Sealant - per tooth |
6,379 |
2,380 |
$201K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,428 |
1,413 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,883 |
1,477 |
$177K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,638 |
7,620 |
$156K |
| D1110 |
Prophylaxis - adult |
2,625 |
2,623 |
$128K |
| D0272 |
Bitewings - two radiographic images |
6,062 |
6,031 |
$126K |
| D1206 |
Topical application of fluoride varnish |
4,794 |
4,791 |
$123K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,182 |
831 |
$85K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,614 |
1,614 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
3,840 |
3,766 |
$55K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
614 |
492 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
627 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,875 |
2,154 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
706 |
698 |
$11K |
| D9920 |
|
129 |
119 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
63 |
$8K |
| D2140 |
|
22 |
13 |
$1K |
| D2330 |
|
17 |
15 |
$1K |