| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
695 |
287 |
$96K |
| D0240 |
|
1,841 |
962 |
$44K |
| D9248 |
|
454 |
440 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,095 |
1,083 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
390 |
171 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,097 |
1,085 |
$26K |
| D1110 |
Prophylaxis - adult |
552 |
549 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
274 |
133 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,122 |
1,110 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
784 |
760 |
$20K |
| D1120 |
Prophylaxis - child |
573 |
565 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
84 |
52 |
$7K |
| D0602 |
|
1,310 |
1,298 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
206 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
123 |
$2K |
| D2140 |
|
19 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$468.80 |