| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,293 |
3,662 |
$950K |
| D1120 |
Prophylaxis - child |
11,758 |
11,366 |
$482K |
| D1351 |
Sealant - per tooth |
6,589 |
3,476 |
$405K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,742 |
11,350 |
$305K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,705 |
2,584 |
$276K |
| D0120 |
Periodic oral evaluation - established patient |
9,615 |
9,299 |
$270K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,061 |
2,961 |
$241K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,176 |
1,737 |
$153K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,097 |
4,899 |
$118K |
| D2140 |
|
2,368 |
1,878 |
$107K |
| D0272 |
Bitewings - two radiographic images |
6,040 |
5,801 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
9,639 |
9,218 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,742 |
7,405 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,498 |
2,397 |
$45K |
| D1110 |
Prophylaxis - adult |
434 |
411 |
$18K |
| D2160 |
|
164 |
151 |
$12K |
| D2330 |
|
194 |
158 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
335 |
$6K |
| D2920 |
|
184 |
175 |
$4K |
| D9110 |
|
42 |
42 |
$2K |