| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,275 |
275 |
$188K |
| D1351 |
Sealant - per tooth |
2,086 |
500 |
$53K |
| D1120 |
Prophylaxis - child |
1,492 |
1,303 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,784 |
1,560 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,286 |
1,127 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
814 |
596 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
126 |
$17K |
| D2140 |
|
264 |
141 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
384 |
323 |
$12K |
| D0272 |
Bitewings - two radiographic images |
465 |
398 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
44 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
470 |
399 |
$6K |
| D1510 |
|
22 |
14 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
45 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
373 |
211 |
$3K |
| D1354 |
|
31 |
12 |
$3K |
| D2331 |
|
21 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$867.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$852.10 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$619.80 |
| D0603 |
|
83 |
76 |
$0.00 |