| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,061 |
463 |
$189K |
| D1120 |
Prophylaxis - child |
3,019 |
3,019 |
$148K |
| D1351 |
Sealant - per tooth |
2,963 |
560 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,698 |
3,698 |
$118K |
| D1206 |
Topical application of fluoride varnish |
4,028 |
4,028 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
502 |
365 |
$70K |
| D1110 |
Prophylaxis - adult |
1,027 |
1,027 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
374 |
181 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,132 |
1,132 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
450 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
229 |
181 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
472 |
458 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,336 |
1,336 |
$22K |
| D3120 |
|
460 |
209 |
$16K |
| D0330 |
Panoramic radiographic image |
253 |
253 |
$12K |
| D1330 |
|
1,156 |
1,156 |
$8K |
| D1517 |
|
27 |
27 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
193 |
182 |
$4K |
| D1516 |
|
19 |
19 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
225 |
223 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
59 |
59 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$946.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$526.98 |