| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,124 |
1,333 |
$322K |
| D1351 |
Sealant - per tooth |
11,124 |
1,973 |
$242K |
| D1120 |
Prophylaxis - child |
4,559 |
4,297 |
$132K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,582 |
862 |
$123K |
| D1206 |
Topical application of fluoride varnish |
4,891 |
4,612 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,335 |
766 |
$76K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,237 |
749 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
3,589 |
3,378 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,238 |
748 |
$70K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,835 |
2,478 |
$53K |
| D9310 |
|
1,319 |
1,242 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
723 |
688 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,189 |
2,057 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,087 |
1,025 |
$29K |
| D0330 |
Panoramic radiographic image |
1,198 |
1,130 |
$24K |
| D0240 |
|
1,220 |
694 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,514 |
1,363 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,613 |
643 |
$11K |
| D1110 |
Prophylaxis - adult |
267 |
257 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
383 |
360 |
$10K |
| D1510 |
|
69 |
63 |
$8K |
| D1354 |
|
1,429 |
385 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
172 |
160 |
$5K |
| D0274 |
Bitewings - four radiographic images |
264 |
251 |
$5K |
| D1353 |
|
43 |
13 |
$814.88 |
| D0603 |
|
301 |
252 |
$0.00 |
| D0601 |
|
77 |
66 |
$0.00 |
| D1999 |
|
156 |
115 |
$0.00 |