| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,728 |
546 |
$532K |
| D1120 |
Prophylaxis - child |
5,307 |
5,301 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
5,176 |
5,173 |
$164K |
| D1206 |
Topical application of fluoride varnish |
5,987 |
5,979 |
$160K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,262 |
808 |
$111K |
| D0272 |
Bitewings - two radiographic images |
2,840 |
2,825 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
767 |
359 |
$65K |
| D1354 |
|
1,598 |
577 |
$43K |
| D9420 |
|
292 |
286 |
$40K |
| D1351 |
Sealant - per tooth |
1,345 |
613 |
$38K |
| D0240 |
|
1,889 |
997 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
610 |
$36K |
| D1110 |
Prophylaxis - adult |
698 |
698 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
122 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,221 |
424 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
720 |
713 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
177 |
176 |
$7K |