| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,107 |
1,149 |
$316K |
| D0120 |
Periodic oral evaluation - established patient |
2,648 |
2,643 |
$228K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,238 |
983 |
$213K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,740 |
1,059 |
$202K |
| D9420 |
|
1,252 |
1,244 |
$142K |
| D2140 |
|
1,064 |
549 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
726 |
330 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
2,924 |
2,908 |
$48K |
| D1351 |
Sealant - per tooth |
1,178 |
324 |
$39K |
| D1120 |
Prophylaxis - child |
2,729 |
2,718 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,054 |
2,043 |
$35K |
| D2332 |
|
385 |
180 |
$28K |
| D2160 |
|
298 |
140 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,172 |
2,771 |
$17K |
| D2330 |
|
170 |
106 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
67 |
$13K |
| D1206 |
Topical application of fluoride varnish |
2,882 |
2,873 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$2K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$518.11 |
| D0274 |
Bitewings - four radiographic images |
324 |
324 |
$264.71 |