| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
435 |
106 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,184 |
1,135 |
$31K |
| D1120 |
Prophylaxis - child |
665 |
640 |
$23K |
| D1110 |
Prophylaxis - adult |
479 |
456 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,116 |
1,071 |
$22K |
| D0272 |
Bitewings - two radiographic images |
815 |
783 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
204 |
109 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
152 |
56 |
$13K |
| D2140 |
|
126 |
71 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
280 |
257 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
43 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
229 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
126 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
146 |
$2K |
| D0603 |
|
361 |
337 |
$2K |
| D9248 |
|
14 |
14 |
$1K |
| D0602 |
|
160 |
146 |
$790.98 |
| D0601 |
|
160 |
150 |
$776.30 |