| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,112 |
1,266 |
$393K |
| D1120 |
Prophylaxis - child |
8,814 |
8,782 |
$310K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,310 |
1,500 |
$309K |
| D0120 |
Periodic oral evaluation - established patient |
10,043 |
10,012 |
$248K |
| D1206 |
Topical application of fluoride varnish |
12,371 |
12,333 |
$247K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,472 |
948 |
$146K |
| D1351 |
Sealant - per tooth |
3,494 |
1,022 |
$128K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,197 |
663 |
$125K |
| D1110 |
Prophylaxis - adult |
2,484 |
2,483 |
$122K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,536 |
3,304 |
$111K |
| D0210 |
Intraoral - complete series of radiographic images |
1,266 |
1,261 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,997 |
1,994 |
$81K |
| D0272 |
Bitewings - two radiographic images |
3,323 |
3,313 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
3,093 |
3,057 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
937 |
925 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,000 |
997 |
$30K |
| D0274 |
Bitewings - four radiographic images |
870 |
869 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
286 |
140 |
$24K |
| D0240 |
|
827 |
826 |
$16K |
| D7111 |
|
82 |
39 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
406 |
404 |
$13K |
| D2934 |
|
47 |
14 |
$6K |
| D3230 |
|
33 |
12 |
$4K |
| D9420 |
|
16 |
16 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$726.92 |
| D9310 |
|
13 |
13 |
$513.63 |