| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,899 |
1,096 |
$257K |
| D1120 |
Prophylaxis - child |
9,092 |
8,984 |
$251K |
| D0120 |
Periodic oral evaluation - established patient |
13,184 |
13,035 |
$235K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,560 |
14,343 |
$213K |
| D1110 |
Prophylaxis - adult |
4,152 |
4,110 |
$144K |
| D0330 |
Panoramic radiographic image |
2,894 |
2,853 |
$132K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,498 |
867 |
$87K |
| D0272 |
Bitewings - two radiographic images |
4,998 |
4,931 |
$87K |
| D1351 |
Sealant - per tooth |
2,402 |
674 |
$60K |
| D0274 |
Bitewings - four radiographic images |
2,396 |
2,347 |
$55K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
386 |
189 |
$31K |
| D2140 |
|
629 |
460 |
$29K |
| D2160 |
|
214 |
116 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
656 |
645 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,167 |
1,142 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
79 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
239 |
237 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
54 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
16 |
$150.00 |