| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,898 |
587 |
$478K |
| D1120 |
Prophylaxis - child |
14,712 |
12,845 |
$373K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,430 |
1,122 |
$229K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,364 |
12,536 |
$203K |
| D1351 |
Sealant - per tooth |
8,312 |
1,732 |
$202K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,461 |
4,497 |
$182K |
| D0120 |
Periodic oral evaluation - established patient |
7,137 |
6,538 |
$181K |
| D0330 |
Panoramic radiographic image |
4,239 |
3,918 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,207 |
637 |
$126K |
| D0140 |
Limited oral evaluation - problem focused |
3,513 |
2,877 |
$120K |
| D0210 |
Intraoral - complete series of radiographic images |
1,444 |
1,401 |
$98K |
| D0272 |
Bitewings - two radiographic images |
6,838 |
5,928 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,196 |
638 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,370 |
2,367 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
9,393 |
4,284 |
$58K |
| D9420 |
|
190 |
187 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,443 |
2,229 |
$49K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,216 |
1,086 |
$39K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$493.49 |