| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,276 |
1,927 |
$611K |
| D1120 |
Prophylaxis - child |
15,415 |
15,101 |
$381K |
| D0120 |
Periodic oral evaluation - established patient |
14,554 |
14,260 |
$320K |
| D1351 |
Sealant - per tooth |
17,550 |
4,078 |
$249K |
| D1206 |
Topical application of fluoride varnish |
16,626 |
16,244 |
$245K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,809 |
14,283 |
$205K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,254 |
2,839 |
$198K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,811 |
1,677 |
$122K |
| D3240 |
|
875 |
464 |
$122K |
| D8670 |
Periodic orthodontic treatment visit |
1,939 |
1,920 |
$112K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,753 |
5,371 |
$92K |
| D0220 |
Intraoral - periapical first radiographic image |
15,285 |
14,860 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,427 |
1,057 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,894 |
1,826 |
$63K |
| D2934 |
|
363 |
161 |
$62K |
| D0210 |
Intraoral - complete series of radiographic images |
1,797 |
1,711 |
$57K |
| D0603 |
|
6,997 |
6,748 |
$57K |
| D0274 |
Bitewings - four radiographic images |
4,612 |
4,567 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
1,830 |
1,805 |
$42K |
| D0602 |
|
3,621 |
3,547 |
$32K |
| D8680 |
|
57 |
33 |
$31K |
| D1110 |
Prophylaxis - adult |
1,956 |
1,838 |
$26K |
| D0272 |
Bitewings - two radiographic images |
4,105 |
3,891 |
$23K |
| D9920 |
|
1,142 |
993 |
$18K |
| D9248 |
|
207 |
128 |
$16K |
| D1510 |
|
116 |
99 |
$14K |
| D3230 |
|
65 |
24 |
$7K |
| D2335 |
|
68 |
58 |
$6K |
| D8660 |
|
98 |
98 |
$4K |
| D2330 |
|
75 |
55 |
$4K |
| D9310 |
|
188 |
188 |
$3K |
| D2331 |
|
20 |
14 |
$1K |
| D0191 |
|
22 |
22 |
$310.00 |
| D9995 |
|
18 |
18 |
$270.00 |
| D1310 |
|
246 |
244 |
$0.00 |
| D1330 |
|
191 |
180 |
$0.00 |