| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,669 |
4,804 |
$769K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,104 |
5,544 |
$475K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,191 |
2,462 |
$464K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
6,679 |
5,024 |
$335K |
| D2335 |
|
1,199 |
783 |
$187K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,174 |
3,444 |
$180K |
| D7111 |
|
3,676 |
3,262 |
$109K |
| D1120 |
Prophylaxis - child |
3,280 |
3,280 |
$108K |
| D1351 |
Sealant - per tooth |
1,492 |
794 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
3,336 |
3,336 |
$75K |
| D2332 |
|
471 |
395 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,274 |
3,274 |
$38K |
| D0330 |
Panoramic radiographic image |
1,049 |
1,049 |
$31K |
| D2330 |
|
537 |
441 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,622 |
1,622 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,931 |
1,930 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,304 |
1,303 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
951 |
950 |
$12K |
| D1510 |
|
79 |
79 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
77 |
$6K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$3K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$1K |
| D9310 |
|
27 |
27 |
$1K |
| D1999 |
|
908 |
908 |
$0.00 |
| D1330 |
|
613 |
613 |
$0.00 |
| D1310 |
|
64 |
64 |
$0.00 |