| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
677 |
171 |
$93K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
536 |
295 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,663 |
1,578 |
$39K |
| D1120 |
Prophylaxis - child |
1,074 |
1,011 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,237 |
1,176 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,199 |
1,152 |
$22K |
| D1110 |
Prophylaxis - adult |
468 |
458 |
$22K |
| D2140 |
|
312 |
190 |
$20K |
| D2160 |
|
145 |
91 |
$13K |
| D1351 |
Sealant - per tooth |
443 |
147 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
491 |
440 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
98 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
84 |
30 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
370 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
208 |
196 |
$7K |
| D0603 |
|
1,462 |
1,403 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
293 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
41 |
$4K |
| D1354 |
|
44 |
13 |
$660.00 |