| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,283 |
661 |
$240K |
| D1120 |
Prophylaxis - child |
7,034 |
6,296 |
$118K |
| D1206 |
Topical application of fluoride varnish |
4,950 |
4,263 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
6,871 |
6,112 |
$101K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,640 |
819 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,386 |
641 |
$82K |
| D1351 |
Sealant - per tooth |
2,718 |
743 |
$58K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,155 |
1,842 |
$55K |
| D2140 |
|
1,305 |
705 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,831 |
2,716 |
$41K |
| D7960 |
|
496 |
289 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,577 |
1,417 |
$38K |
| D0330 |
Panoramic radiographic image |
652 |
588 |
$30K |
| D1110 |
Prophylaxis - adult |
1,012 |
923 |
$29K |
| D0272 |
Bitewings - two radiographic images |
3,156 |
2,836 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
362 |
208 |
$25K |
| D0240 |
|
2,014 |
717 |
$16K |
| D2330 |
|
157 |
104 |
$9K |
| D0350 |
|
728 |
648 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
388 |
349 |
$7K |
| D0274 |
Bitewings - four radiographic images |
364 |
341 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
335 |
$2K |
| D2160 |
|
16 |
12 |
$937.25 |
| D9420 |
|
649 |
612 |
$0.00 |