| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,009 |
438 |
$223K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,093 |
942 |
$222K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,630 |
841 |
$171K |
| D1351 |
Sealant - per tooth |
5,146 |
1,201 |
$137K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,763 |
668 |
$115K |
| D1120 |
Prophylaxis - child |
3,411 |
3,410 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,639 |
3,638 |
$96K |
| D0330 |
Panoramic radiographic image |
1,293 |
1,292 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,582 |
2,581 |
$61K |
| D9110 |
|
1,229 |
1,220 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,258 |
2,256 |
$53K |
| D1110 |
Prophylaxis - adult |
1,053 |
1,053 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
884 |
883 |
$32K |
| D2933 |
|
209 |
73 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,594 |
1,594 |
$29K |
| D3240 |
|
157 |
93 |
$27K |
| D1330 |
|
3,090 |
3,090 |
$15K |
| D1510 |
|
51 |
41 |
$8K |
| D2330 |
|
119 |
74 |
$8K |
| D0603 |
|
719 |
719 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$547.52 |