| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,823 |
1,155 |
$356K |
| D0120 |
Periodic oral evaluation - established patient |
12,164 |
11,108 |
$292K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,284 |
1,935 |
$243K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,582 |
1,960 |
$243K |
| D1120 |
Prophylaxis - child |
9,060 |
8,550 |
$232K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,540 |
4,726 |
$220K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,227 |
11,222 |
$180K |
| D1110 |
Prophylaxis - adult |
4,446 |
4,169 |
$156K |
| D1351 |
Sealant - per tooth |
6,501 |
1,856 |
$153K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,155 |
874 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,303 |
830 |
$122K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,176 |
605 |
$99K |
| D0272 |
Bitewings - two radiographic images |
4,433 |
4,152 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,473 |
1,405 |
$63K |
| D0330 |
Panoramic radiographic image |
1,222 |
1,126 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
3,151 |
2,884 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,336 |
1,214 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
972 |
914 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,506 |
1,240 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
16 |
$608.16 |
| D0250 |
|
15 |
12 |
$270.12 |
| D1206 |
Topical application of fluoride varnish |
19 |
17 |
$268.48 |