| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,419 |
697 |
$264K |
| D1120 |
Prophylaxis - child |
3,869 |
3,864 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
3,883 |
3,878 |
$126K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,040 |
510 |
$90K |
| D7140 |
Extraction, erupted tooth or exposed root |
914 |
513 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
944 |
938 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,102 |
2,099 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,860 |
1,858 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
198 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,660 |
1,657 |
$41K |
| D1351 |
Sealant - per tooth |
738 |
274 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,039 |
1,030 |
$19K |
| D1110 |
Prophylaxis - adult |
366 |
365 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
125 |
86 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
757 |
562 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$6K |
| D2140 |
|
77 |
53 |
$6K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$5K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$3K |
| D9420 |
|
14 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$2K |
| D9248 |
|
27 |
26 |
$1K |