| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
266 |
170 |
$53K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
471 |
281 |
$44K |
| D1120 |
Prophylaxis - child |
557 |
557 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
338 |
337 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
567 |
567 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
180 |
109 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
472 |
472 |
$16K |
| D2140 |
|
210 |
153 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
58 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
638 |
279 |
$9K |
| D0272 |
Bitewings - two radiographic images |
307 |
307 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
360 |
$7K |
| D2160 |
|
36 |
26 |
$4K |
| D2331 |
|
15 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
16 |
$1K |