| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,064 |
974 |
$524K |
| D1120 |
Prophylaxis - child |
7,789 |
7,475 |
$231K |
| D0120 |
Periodic oral evaluation - established patient |
8,201 |
7,868 |
$166K |
| D0272 |
Bitewings - two radiographic images |
7,354 |
6,860 |
$112K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,879 |
6,566 |
$104K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,627 |
510 |
$68K |
| D1206 |
Topical application of fluoride varnish |
2,217 |
2,129 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,757 |
1,671 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
592 |
282 |
$38K |
| D0240 |
|
2,602 |
1,127 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,719 |
1,537 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
563 |
259 |
$29K |
| D1999 |
|
1,550 |
1,435 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,871 |
2,199 |
$25K |
| D1110 |
Prophylaxis - adult |
505 |
490 |
$19K |
| D0330 |
Panoramic radiographic image |
358 |
354 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
542 |
$13K |
| D0274 |
Bitewings - four radiographic images |
340 |
329 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
343 |
$4K |
| D3230 |
|
30 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
151 |
36 |
$3K |
| D9420 |
|
867 |
719 |
$0.00 |