| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,789 |
1,102 |
$586K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,757 |
2,708 |
$294K |
| D1120 |
Prophylaxis - child |
11,100 |
10,998 |
$277K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,524 |
990 |
$177K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,723 |
5,667 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,918 |
1,782 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
7,250 |
7,187 |
$166K |
| D1351 |
Sealant - per tooth |
5,782 |
1,930 |
$158K |
| D1206 |
Topical application of fluoride varnish |
8,239 |
8,174 |
$142K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,490 |
3,286 |
$118K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,292 |
4,239 |
$92K |
| D0330 |
Panoramic radiographic image |
1,030 |
1,020 |
$84K |
| D1354 |
|
4,590 |
1,287 |
$84K |
| D0272 |
Bitewings - two radiographic images |
6,382 |
6,310 |
$72K |
| D0240 |
|
5,379 |
2,412 |
$70K |
| D0210 |
Intraoral - complete series of radiographic images |
510 |
507 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,693 |
2,666 |
$58K |
| D1110 |
Prophylaxis - adult |
1,499 |
1,485 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
603 |
440 |
$38K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
292 |
139 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
510 |
500 |
$15K |
| D2332 |
|
39 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
481 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
112 |
$1K |
| D9215 |
|
176 |
169 |
$0.00 |
| D9920 |
|
87 |
81 |
$0.00 |
| D9210 |
|
14 |
14 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$0.00 |