| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,802 |
351 |
$238K |
| D0120 |
Periodic oral evaluation - established patient |
6,465 |
6,315 |
$156K |
| D1110 |
Prophylaxis - adult |
3,110 |
3,057 |
$140K |
| D1120 |
Prophylaxis - child |
3,797 |
3,686 |
$119K |
| D0272 |
Bitewings - two radiographic images |
5,016 |
4,911 |
$107K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,370 |
686 |
$102K |
| D1206 |
Topical application of fluoride varnish |
3,207 |
3,093 |
$58K |
| D1351 |
Sealant - per tooth |
2,020 |
606 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
560 |
245 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,976 |
1,971 |
$37K |
| D0240 |
|
1,625 |
869 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,438 |
1,353 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
1,031 |
995 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
274 |
98 |
$22K |
| D2140 |
|
210 |
146 |
$12K |
| D0603 |
|
2,609 |
2,544 |
$10K |
| D0602 |
|
2,040 |
1,997 |
$8K |
| D0601 |
|
1,846 |
1,793 |
$7K |
| D0330 |
Panoramic radiographic image |
131 |
120 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
268 |
$4K |
| D2330 |
|
23 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D2160 |
|
14 |
12 |
$1K |
| D9248 |
|
13 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
65 |
$860.24 |
| D9420 |
|
27 |
26 |
$0.00 |