| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
287 |
54 |
$44K |
| D1120 |
Prophylaxis - child |
692 |
690 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
78 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
708 |
706 |
$12K |
| D1110 |
Prophylaxis - adult |
173 |
171 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
92 |
45 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
278 |
$6K |
| D1351 |
Sealant - per tooth |
197 |
67 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
146 |
$6K |
| D2140 |
|
87 |
60 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$5K |
| D0272 |
Bitewings - two radiographic images |
200 |
200 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$2K |
| D9420 |
|
13 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$275.00 |