| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,370 |
398 |
$161K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,375 |
876 |
$157K |
| D1120 |
Prophylaxis - child |
2,722 |
2,716 |
$135K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,362 |
398 |
$133K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,417 |
1,416 |
$93K |
| D2140 |
|
1,712 |
799 |
$92K |
| D1310 |
|
1,833 |
1,830 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,904 |
2,896 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,077 |
505 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
911 |
910 |
$60K |
| D1351 |
Sealant - per tooth |
1,566 |
562 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,491 |
2,695 |
$54K |
| D2160 |
|
664 |
334 |
$52K |
| D0145 |
Oral evaluation for a patient under three years of age |
579 |
577 |
$38K |
| D0603 |
|
1,817 |
1,812 |
$26K |
| D0350 |
|
2,602 |
1,012 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,108 |
2,086 |
$25K |
| D2331 |
|
233 |
143 |
$18K |
| D0272 |
Bitewings - two radiographic images |
705 |
705 |
$8K |
| D2330 |
|
104 |
61 |
$8K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$4K |