| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,476 |
845 |
$349K |
| D1120 |
Prophylaxis - child |
7,843 |
7,273 |
$253K |
| D1351 |
Sealant - per tooth |
8,917 |
1,604 |
$233K |
| D1206 |
Topical application of fluoride varnish |
10,886 |
10,088 |
$223K |
| D0120 |
Periodic oral evaluation - established patient |
10,081 |
9,357 |
$215K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,747 |
1,418 |
$171K |
| D1110 |
Prophylaxis - adult |
3,943 |
3,637 |
$165K |
| D0272 |
Bitewings - two radiographic images |
4,793 |
4,452 |
$109K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,196 |
2,536 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
820 |
354 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,149 |
1,957 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,520 |
1,405 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
908 |
500 |
$42K |
| D1352 |
|
698 |
229 |
$23K |
| D0240 |
|
1,481 |
713 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
272 |
198 |
$20K |
| D0330 |
Panoramic radiographic image |
347 |
322 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
998 |
883 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
89 |
50 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
157 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
204 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
25 |
16 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
39 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
41 |
$698.40 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$551.09 |