| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
285 |
152 |
$36K |
| D1351 |
Sealant - per tooth |
616 |
238 |
$35K |
| D1120 |
Prophylaxis - child |
850 |
709 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
850 |
709 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
614 |
515 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
246 |
156 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
532 |
442 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
121 |
65 |
$9K |
| D9110 |
|
104 |
96 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
89 |
58 |
$6K |
| D0274 |
Bitewings - four radiographic images |
307 |
258 |
$5K |
| D1110 |
Prophylaxis - adult |
123 |
105 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
793 |
665 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
721 |
497 |
$4K |
| D0272 |
Bitewings - two radiographic images |
392 |
333 |
$3K |
| D2140 |
|
83 |
54 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$631.80 |