| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,280 |
590 |
$725K |
| D1120 |
Prophylaxis - child |
5,542 |
5,169 |
$324K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,899 |
465 |
$222K |
| D0120 |
Periodic oral evaluation - established patient |
4,820 |
4,509 |
$213K |
| D3221 |
|
986 |
285 |
$176K |
| D1206 |
Topical application of fluoride varnish |
5,669 |
5,382 |
$151K |
| D1351 |
Sealant - per tooth |
2,352 |
624 |
$102K |
| D0272 |
Bitewings - two radiographic images |
2,591 |
2,403 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,009 |
958 |
$62K |
| D0240 |
|
1,699 |
835 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
995 |
833 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,574 |
513 |
$30K |
| D1110 |
Prophylaxis - adult |
298 |
297 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
785 |
749 |
$18K |
| D0330 |
Panoramic radiographic image |
112 |
109 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
478 |
364 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
90 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$2K |