| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
853 |
164 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
1,464 |
934 |
$38K |
| D1120 |
Prophylaxis - child |
969 |
601 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,355 |
850 |
$27K |
| D2140 |
|
335 |
182 |
$22K |
| D0272 |
Bitewings - two radiographic images |
813 |
520 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
738 |
419 |
$19K |
| D1110 |
Prophylaxis - adult |
413 |
280 |
$19K |
| D1351 |
Sealant - per tooth |
669 |
159 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
59 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
156 |
103 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
481 |
292 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
390 |
238 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$598.50 |
| D0602 |
|
331 |
205 |
$417.44 |
| D0601 |
|
184 |
108 |
$271.25 |
| D0603 |
|
218 |
135 |
$216.66 |