| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,309 |
470 |
$247K |
| D1120 |
Prophylaxis - child |
2,767 |
2,765 |
$106K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,220 |
742 |
$104K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
781 |
376 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,114 |
3,112 |
$88K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,024 |
511 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,095 |
3,093 |
$75K |
| D2332 |
|
385 |
225 |
$46K |
| D9420 |
|
287 |
287 |
$42K |
| D1110 |
Prophylaxis - adult |
847 |
846 |
$41K |
| D1351 |
Sealant - per tooth |
1,182 |
388 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,408 |
1,407 |
$33K |
| D2140 |
|
464 |
315 |
$32K |
| D0330 |
Panoramic radiographic image |
400 |
398 |
$28K |
| D2330 |
|
296 |
179 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,305 |
1,297 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
416 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,716 |
781 |
$18K |
| D2160 |
|
156 |
103 |
$16K |
| D1510 |
|
78 |
59 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
192 |
$8K |
| D0274 |
Bitewings - four radiographic images |
194 |
194 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
200 |
200 |
$6K |
| D2331 |
|
45 |
27 |
$5K |
| D9920 |
|
72 |
70 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |