| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,843 |
777 |
$196K |
| D1120 |
Prophylaxis - child |
7,650 |
6,857 |
$162K |
| D0120 |
Periodic oral evaluation - established patient |
7,841 |
7,112 |
$110K |
| D1206 |
Topical application of fluoride varnish |
4,854 |
4,323 |
$105K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,160 |
1,004 |
$102K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,205 |
1,154 |
$87K |
| D1351 |
Sealant - per tooth |
4,565 |
807 |
$84K |
| D0272 |
Bitewings - two radiographic images |
3,581 |
3,203 |
$55K |
| D2140 |
|
1,289 |
766 |
$43K |
| D1110 |
Prophylaxis - adult |
1,450 |
1,327 |
$42K |
| D0330 |
Panoramic radiographic image |
933 |
832 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,610 |
1,380 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,212 |
3,831 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
250 |
122 |
$18K |
| D2330 |
|
367 |
195 |
$18K |
| D2332 |
|
256 |
130 |
$16K |
| D0274 |
Bitewings - four radiographic images |
643 |
585 |
$15K |
| D0240 |
|
1,309 |
1,171 |
$14K |
| D9920 |
|
880 |
732 |
$12K |
| D1510 |
|
107 |
95 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
468 |
426 |
$8K |
| D2331 |
|
130 |
82 |
$7K |
| D2160 |
|
209 |
146 |
$6K |
| D2335 |
|
162 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
41 |
$291.50 |