| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
11,128 |
2,051 |
$1.75M |
| D2390 |
|
1,163 |
360 |
$269K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,000 |
516 |
$93K |
| D1351 |
Sealant - per tooth |
3,885 |
1,121 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,127 |
2,075 |
$87K |
| D1206 |
Topical application of fluoride varnish |
2,650 |
2,585 |
$61K |
| D2330 |
|
821 |
453 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
839 |
446 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
584 |
273 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,587 |
2,516 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,678 |
2,596 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
50 |
$10K |
| D2331 |
|
95 |
50 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,572 |
2,438 |
$6K |
| D1510 |
|
32 |
24 |
$3K |
| D1999 |
|
176 |
168 |
$2K |