| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,101 |
2,203 |
$996K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,462 |
2,460 |
$753K |
| D1120 |
Prophylaxis - child |
17,034 |
16,866 |
$541K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,644 |
2,004 |
$356K |
| D0120 |
Periodic oral evaluation - established patient |
14,529 |
14,464 |
$335K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,870 |
1,561 |
$305K |
| D1351 |
Sealant - per tooth |
8,215 |
2,369 |
$279K |
| D1110 |
Prophylaxis - adult |
4,476 |
4,460 |
$191K |
| D1206 |
Topical application of fluoride varnish |
10,377 |
10,100 |
$185K |
| D2934 |
|
1,048 |
286 |
$176K |
| D0210 |
Intraoral - complete series of radiographic images |
2,695 |
2,669 |
$170K |
| D0272 |
Bitewings - two radiographic images |
7,761 |
7,709 |
$160K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,215 |
4,892 |
$160K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,859 |
1,005 |
$157K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,062 |
11,990 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,825 |
3,815 |
$148K |
| D9420 |
|
909 |
907 |
$100K |
| D0220 |
Intraoral - periapical first radiographic image |
7,854 |
7,761 |
$97K |
| D0240 |
|
4,852 |
4,814 |
$93K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,380 |
3,360 |
$64K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,947 |
1,947 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,782 |
1,760 |
$60K |
| D3120 |
|
1,570 |
801 |
$57K |
| D9219 |
|
1,247 |
1,232 |
$50K |
| D2330 |
|
373 |
225 |
$36K |
| D0350 |
|
558 |
480 |
$31K |
| D0274 |
Bitewings - four radiographic images |
973 |
972 |
$28K |
| D2332 |
|
129 |
76 |
$19K |
| D0330 |
Panoramic radiographic image |
365 |
365 |
$19K |
| D1510 |
|
128 |
97 |
$18K |
| D0190 |
|
1,021 |
1,019 |
$17K |
| D0170 |
|
517 |
511 |
$16K |
| D2331 |
|
102 |
67 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
39 |
$8K |
| D1354 |
|
1,070 |
346 |
$7K |
| D3230 |
|
40 |
12 |
$5K |
| D9995 |
|
12 |
12 |
$180.95 |