| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,247 |
485 |
$239K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,173 |
700 |
$157K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,235 |
601 |
$80K |
| D1120 |
Prophylaxis - child |
2,107 |
2,105 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,634 |
3,630 |
$75K |
| D1351 |
Sealant - per tooth |
2,601 |
728 |
$64K |
| D1110 |
Prophylaxis - adult |
1,680 |
1,677 |
$63K |
| D1206 |
Topical application of fluoride varnish |
3,080 |
3,075 |
$55K |
| D0330 |
Panoramic radiographic image |
1,083 |
1,081 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
699 |
389 |
$38K |
| D0274 |
Bitewings - four radiographic images |
983 |
981 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
381 |
243 |
$27K |
| D9110 |
|
472 |
469 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
189 |
113 |
$15K |
| D0272 |
Bitewings - two radiographic images |
897 |
897 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
396 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
847 |
837 |
$7K |
| D2390 |
|
35 |
13 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
235 |
$4K |
| D2330 |
|
87 |
54 |
$4K |
| D2331 |
|
56 |
36 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
166 |
166 |
$3K |
| D1510 |
|
18 |
13 |
$2K |