| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,875 |
359 |
$364K |
| D7140 |
Extraction, erupted tooth or exposed root |
829 |
403 |
$83K |
| D1206 |
Topical application of fluoride varnish |
2,103 |
2,080 |
$71K |
| D1120 |
Prophylaxis - child |
1,496 |
1,479 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,748 |
1,730 |
$60K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
401 |
261 |
$47K |
| D0274 |
Bitewings - four radiographic images |
984 |
977 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
263 |
140 |
$34K |
| D1110 |
Prophylaxis - adult |
547 |
544 |
$33K |
| D9420 |
|
328 |
325 |
$30K |
| D2140 |
|
298 |
178 |
$26K |
| D0330 |
Panoramic radiographic image |
307 |
304 |
$25K |
| D0272 |
Bitewings - two radiographic images |
704 |
696 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
240 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
95 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
679 |
670 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
62 |
25 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
312 |
224 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
82 |
$5K |
| D2160 |
|
12 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$242.00 |