| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,447 |
1,478 |
$497K |
| D1120 |
Prophylaxis - child |
12,597 |
12,595 |
$468K |
| D0120 |
Periodic oral evaluation - established patient |
14,202 |
14,202 |
$417K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,098 |
1,869 |
$287K |
| D1351 |
Sealant - per tooth |
8,115 |
3,468 |
$257K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,955 |
10,955 |
$231K |
| D1110 |
Prophylaxis - adult |
4,341 |
4,339 |
$230K |
| D9920 |
|
2,549 |
2,363 |
$173K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,185 |
1,307 |
$170K |
| D0272 |
Bitewings - two radiographic images |
6,526 |
6,514 |
$147K |
| D1206 |
Topical application of fluoride varnish |
5,038 |
5,036 |
$129K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,750 |
1,750 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
4,155 |
4,120 |
$65K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
382 |
249 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,937 |
2,697 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
929 |
780 |
$37K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
180 |
121 |
$17K |
| D0330 |
Panoramic radiographic image |
191 |
191 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
54 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
406 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |