| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,772 |
436 |
$460K |
| D1120 |
Prophylaxis - child |
4,953 |
4,683 |
$294K |
| D0120 |
Periodic oral evaluation - established patient |
4,530 |
4,287 |
$200K |
| D0274 |
Bitewings - four radiographic images |
3,251 |
3,068 |
$181K |
| D1206 |
Topical application of fluoride varnish |
5,325 |
4,999 |
$140K |
| D7140 |
Extraction, erupted tooth or exposed root |
900 |
253 |
$104K |
| D1351 |
Sealant - per tooth |
2,057 |
521 |
$92K |
| D0272 |
Bitewings - two radiographic images |
1,518 |
1,406 |
$56K |
| D4355 |
|
315 |
275 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
785 |
669 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,293 |
560 |
$42K |
| D0330 |
Panoramic radiographic image |
444 |
403 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
175 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
763 |
599 |
$34K |
| D0240 |
|
1,178 |
558 |
$32K |
| D1110 |
Prophylaxis - adult |
364 |
344 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,023 |
919 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
209 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
199 |
183 |
$10K |
| D9420 |
|
64 |
64 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
93 |
$3K |
| D9310 |
|
26 |
24 |
$2K |