| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
551 |
288 |
$56K |
| D1120 |
Prophylaxis - child |
1,317 |
1,314 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,398 |
1,396 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
207 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,132 |
1,130 |
$17K |
| D1351 |
Sealant - per tooth |
499 |
152 |
$11K |
| D0272 |
Bitewings - two radiographic images |
967 |
966 |
$10K |
| D0330 |
Panoramic radiographic image |
209 |
209 |
$9K |
| D1206 |
Topical application of fluoride varnish |
508 |
507 |
$8K |
| D1110 |
Prophylaxis - adult |
220 |
218 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
278 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
86 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
57 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
85 |
$4K |
| D0240 |
|
235 |
195 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
440 |
324 |
$4K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
51 |
43 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
117 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
525 |
516 |
$3K |