| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,399 |
1,109 |
$334K |
| D1351 |
Sealant - per tooth |
12,216 |
3,117 |
$326K |
| D0120 |
Periodic oral evaluation - established patient |
7,820 |
7,725 |
$215K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,688 |
1,489 |
$204K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,358 |
1,348 |
$189K |
| D1120 |
Prophylaxis - child |
4,899 |
4,839 |
$172K |
| D9248 |
|
1,478 |
1,447 |
$170K |
| D1110 |
Prophylaxis - adult |
3,130 |
3,087 |
$163K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,968 |
966 |
$156K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,070 |
7,966 |
$114K |
| D0274 |
Bitewings - four radiographic images |
2,977 |
2,931 |
$97K |
| D2140 |
|
1,558 |
1,034 |
$89K |
| D0272 |
Bitewings - two radiographic images |
3,655 |
3,603 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
6,358 |
6,213 |
$75K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,410 |
824 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,270 |
5,515 |
$67K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,845 |
1,733 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
643 |
629 |
$21K |
| D2160 |
|
183 |
149 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
333 |
321 |
$6K |
| D0603 |
|
9,896 |
9,797 |
$0.00 |
| D0602 |
|
42 |
42 |
$0.00 |