| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
974 |
266 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
4,127 |
3,085 |
$108K |
| D1120 |
Prophylaxis - child |
2,949 |
2,177 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,984 |
2,953 |
$79K |
| D0272 |
Bitewings - two radiographic images |
3,045 |
2,270 |
$74K |
| D1110 |
Prophylaxis - adult |
1,175 |
906 |
$54K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
450 |
242 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
972 |
724 |
$25K |
| D1351 |
Sealant - per tooth |
907 |
198 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
258 |
205 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
817 |
590 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
169 |
65 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
358 |
244 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
52 |
$5K |
| D9248 |
|
53 |
53 |
$5K |
| D2140 |
|
77 |
44 |
$5K |
| D0603 |
|
391 |
240 |
$2K |
| D1206 |
Topical application of fluoride varnish |
81 |
81 |
$2K |
| D0602 |
|
80 |
48 |
$400.00 |
| D0601 |
|
42 |
41 |
$210.00 |