| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,897 |
1,522 |
$343K |
| D1120 |
Prophylaxis - child |
11,069 |
10,919 |
$304K |
| D0120 |
Periodic oral evaluation - established patient |
15,587 |
15,383 |
$276K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,099 |
16,872 |
$251K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,338 |
1,822 |
$189K |
| D0330 |
Panoramic radiographic image |
3,796 |
3,730 |
$175K |
| D1110 |
Prophylaxis - adult |
4,390 |
4,324 |
$151K |
| D0272 |
Bitewings - two radiographic images |
6,170 |
6,079 |
$108K |
| D2140 |
|
2,256 |
1,434 |
$104K |
| D1351 |
Sealant - per tooth |
3,535 |
1,181 |
$88K |
| D0274 |
Bitewings - four radiographic images |
2,582 |
2,545 |
$60K |
| D2160 |
|
712 |
411 |
$49K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
351 |
198 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,727 |
1,690 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
295 |
203 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
432 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
307 |
305 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
50 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$260.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$180.00 |