| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,690 |
1,488 |
$767K |
| D1120 |
Prophylaxis - child |
14,086 |
13,759 |
$309K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,808 |
14,472 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
12,217 |
11,935 |
$230K |
| D0272 |
Bitewings - two radiographic images |
9,981 |
9,727 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,877 |
2,822 |
$84K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
653 |
306 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
1,839 |
1,783 |
$45K |
| D1110 |
Prophylaxis - adult |
1,109 |
1,077 |
$35K |
| D0240 |
|
2,823 |
1,368 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
446 |
274 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
384 |
215 |
$19K |
| D1351 |
Sealant - per tooth |
357 |
92 |
$8K |
| D2933 |
|
48 |
13 |
$7K |
| D0274 |
Bitewings - four radiographic images |
344 |
340 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
13 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
14 |
$694.80 |